Compartment Syndrome

Andre H Simarmata

11-2013-145
Overview of Compartment
Syndrome
 Compartment syndrome occurs when
extremely high pressures build in
confined space
 Blood supply is dramatically reduced to
muscles in a closed body space, known as
a compartment. Compartments are
found in the hand, forearm, upper arm,
abdomen, buttock and leg.
 The muscles most frequently involved are
those on the front of the lower leg or
palm side of the forearm.
compartment syndrome is an
emergency

 If not diagnosed and treated promptly

there can be permanent nerve injury and
loss of muscle function.
 Permanent nerve injury can occur after
12-24 hours.
 In severe cases limbs may need to be
amputated because all of the muscles in
the compartment have died from lack of
O2.
Categories of Etiologies
1. Decreased Compartment Size
 Caused by restrictive dressings, splints or
casts, excessive traction, premature closure
of fascia

2. Increased Compartment Content

 Bleeding or swelling within compartment
 Can also result from interstitial IV into
compartment

3. Externally Applied Pressure

 Constrictive dressing, prolonged compression
from lying on limb
 Etiology
 Bleeding from a bone fracture
 Burn eschar
 Casts applied too tightly
 Crush injuries
 Leaking of IVF
into the compartment
 Seizures that involve the muscles in a
compartment
 Snake bite
 Swelling of the muscle itself
 Compartments are groups of
muscles surrounded by
inelastic fascia.
 Increased pressure within a
muscle compartment causes
decreased blood supply to
affected muscles.
 Any swelling of muscles leaves
no room for expansion and
blood supply is progressively
shut off.
 If affected muscles are
deprived of blood supply for >
6 hours, nerve and muscle
tissue can be permanently
damaged.
Pathophysiology
 elevation of interstitial pressure in closed fascial
compartment (limited space) that results in
microvascular compromise
 Capillary blood perfusion  which prevents
adequate circulation & compromises tissue
viability metabolic demands not met 
ischemia & anaerobic metabolism  histamine
release by affected muscles   edema & 
perfusion
 as duration & magnitude of interstitial pressure
increases, myoneural function is impaired &
necrosis of soft tissues eventually develops
 Left untreated  nerve & muscle function loss,
infection, myoglobinuria, renal failure,
amputation
 Nerve Ischemia
1 hour - normal conduction
 1- 4 hours - neuropraxic damage
reversible
 8 hours - axonotmesis and
irreversible change
Compartment Syndrome/Edema-Ischemia
Cycle
Source: Orthopaedic Nursing, 2001, 20(3), 17.
Types
 Acute
 Most severe
 Often requires immediate surgical intervention
 Symptoms present usually within 6-8 hrs of
injury but can take as long as 2 days
 Caused by external or internal forces
secondary to trauma of muscle compartment
 External pressure ’s compartment size while
internal pressure ’s compartment contents
which results in tissue necrosis
 Associated with ’ing pain disproportionate to
type of injury
 Deep, unrelenting pain; throbbing & localized
 Pain with passive stretch
 Numbness & tingling or paresthesias in
affected limb
Types cont.
 Chronic or Exertional
 With exercise & overuse of muscle groups 
inflammation & swelling which 
intracompartmental pressures  aching pain,
tight squeezing sensation but usually relieved
by rest
 Most frequently in young, active individuals
 c/o aching, tightness, cramping in affected
limb, localized to affected compartment &
often bilaterally
 Symptoms often disappear with rest
Types cont.
 Crush Syndrome
 From prolonged compression of skeletal
muscle or severe soft tissue crush trauma 
bleeding, edema, fluid shifts contribute to
injury
 Multi-compartmental involvement results in
systemic effect of severe muscle ischemia 
muscle necrosis and/or infarction
 Leads to muscle infarction, myoglobinemia,
rhabdomyolysis
Hallmark Symptoms of
Compartment Syndrome
 Severe pain or
parasthesia
disproportionate to
the injury
 Increase in pain after
pain medication has
been administered.
 In severe cases there
may be decreased
sensation, weakness
and paleness of the
skin.
History and Physical Exam:
Look for the 6 P’s
Subjective info:
Pain
Pressure
Parasthesia

Objective info:
Pallor
Pulselessness
Paresis
Diagnosis
 A swollen limb,
tense on palpation,
in an intrinsic
minimus position
strongly indicates
compartment
syndrome.
 Diagnosis is based
on high degree of
clinical suspicion
 Tissue Pressure
 Normal tissue pressure
 0-4 mm Hg
 8-10 with exertion
 Absolute pressure theory
 30 mm Hg - Mubarak
 45 mm Hg - Matsen
 Pressure gradient theory
 < 20 mm Hg of diastolic pressure –
Whitesides
 < 30 mm Hg of diastolic pressure McQueen,
et al
 Tissue-Pressure:
Principles
 Heckman et al
demonstrated that
pressure within a given
compartment is not
uniform
 They found tissue pressures
to be highest at the site
or within 5cm of the
injury
 3 of their 5 patients
requiring fasciotomies had
sub-critical pressure values
5cm from the site of highest
pressure
Pressure
Measurement
 Infusion  Arterial line
 manometer  16 - 18 ga.
 saline
Needle
 3-way stopcock
(5-19 mm Hg
higher)
(Whitesides, CORR
 transducer
1975)
 monitor
 Catheter
 wick  Stryker device
 slit catheter  Side port
needle
 Needle Infusion Technique-Historical
 Needle inserted into muscle,
tube with air/saline interval
kept at this height,
manometer indicates
pressure
 Air injected by syringe via 3-
way stopcock
 When the pressure of the saline

injected air exceeds the

compartment pressure
pressure, the saline interval
moves in the tube
 AT this point, the second
person reads the pressure
from the manometer
Common sites of CS
 FOOT
 -Classic signs What are they?
expected with foot fractures and
injury so tense tissue bulging maybe
the most reliable sign.
-associated with CS of deep posterior
compartment of leg.
CS of the hand
Symptoms from compression causes
pain, loss of sensation and
decreased hand function due to
pressure on blood vessels and the
median nerve within the wrist
compartment .
CS of the gluteal region
The large gluteal muscle mass is
confined in fascia hence area prone
to CS. How?

Signs include pain especially on

passive flexion at the hip and tense
swelling of the buttock. Late signs
include foot drop with a loss of
sensation along distribution of sciatic
nerve and no active movements of
the ankle.
Treatment
 A surgical procedure
known as fasciotomy
may be used to open
the membrane leading
to the affected muscles.
 Pressure is relieved and
the blood flow can
return to normal. Often
the skin needs to be
left open for a few
days. It can be closed
with sutures or a skin
graft after swelling
diminishes.
 Treatment
 Fasciotomy
 One incision
• With or without
Fibulectomy

 Two incisions
 All
4
compartments
must be released
 Not selective
One Incision

 Direct lateral incision

 Perifibular
Fasciotomy
 One incision
 Head of fibula to proximal tip of lateral
malleolus
 Incise fascia between soleus and FHL
distally and extended proximally to
origin of soleus from fibula
 Deep posterior compartment released
off of the interosseous membrane,
approached from the interval between
the lateral and superfical posterior
compartments
 Alternative
Through
intermuscular
septum to
reach
superficial
posterior
compartment
Two incisions
Lateral Medial
Double Incision
 2 vertical incisions separated by a
skin bridge of at least 8 cm
 Anterolateral Incision: from knee to
ankle, centered over interval
between anterior and lateral
compartments
Double Incision
 Posteromedial Incision: centered
1-2cm behind posteromedial
border of tibia

 Soleus must be detached from

tibia in order to adequately
decompress proximal portion of
deep posterior compartment
Compartments of the
Forearm
 Forearm can be divided into 3
compartments: Dorsal, Volar
and “Mobile Wad”
 Mobile Wad: Brachioradialis,
ECRL, ECRB
 Dorsal: EPB, EPL, ECU, EDC
 Volar: FPL, FCR, FCU, FDS, FDP,
PQ
 Henry Approach
 Incision begins proximal to
antecubital fossa and extends
across carpal tunnel

 Begins lateral to biceps

tendon, crosses elbow crease
and extends radially, then it is
extended distally along medial
aspect of brachioradialis and
extends across the palm along
the thenar crease

 Alternatively, a straight
incision from lateral biceps to
radial styloid can be used.
 Henry Approach

 Fascia over superficial

muscles is incised

 Care of NV structures
 Henry Approach

 Brachioradialis and
superficial radial n. are
retracted radially and
FCR and radial artery
are retracted ulnar to
expose the deep volar
muscles

 Fascia of each of the

deep muscles is then
incised
Post Fasciotomy…
 Must get bone stability
 IMN

 exfix

 ~48hrs after procedure patient

should be brought back to OR
for further debridement
 Delayed skin closure or skin-
grafting 3-7 days after the
fasciotomies
Remember…
 Fasciotomies are not benign
 Complications are real >25%
 Chronic swelling
 Chronic pain

 Muscle weakness

 Iatrogenic NV injury

 Cosmetic concerns
Prognosis
 Accurate and prompt
diagnosis is necessary to
assure a good outcome.
 Only 8% of patients will
regain function if surgery
is delayed.
 Little or no return of
function can be expected if
dx and tx are delayed.
 Surgery performed days
after injury
contraindicated due to
If surgery performed severe infection and
within 12 hours after difficulty in managing
onset of acute CS, necrotic muscle.
prognosis is good.