Acute
Compartment
syndrome
David Agolley
department of orthopaedics
Definition
Acute Compartment Syndrome occurs when
there is elevated pressure in a closed fascial
(osteofascial) space, resulting in a critical
reduction of blood flow to the tissues
contained within.
Acute Compartment
Syndrome
Variations
Acute Compartment Syndrome
Exertional Compartment syndrome
Crush Syndrome
Acute Compartment
Syndrome
Historical Review
Late complications of ischaemic
contracture
Volkman, 1881
Paralysis and ischaemia, too-tight
bandaging of the forearm and
hand,arterial blockage and
irreversible contracture.
Leser 1884 - animal studies
Brooks 1922 - venous obstruction
Griffiths 1940 - Pain with.. , Painful onset,
Pallor, Puffiness
Bardenheuer 1911 - fasciotomy forearm
Whitesides, Hargens and Mubarak, and
Matsen 1970’s - tissue pressure
measurement techniques.
Current - sustained microcirculatory
impairment,
Still occurs. Not uncommon
Acute Compartment
Syndrome
Acute Compartment
Syndrome
Epidemiology
3.1 per 100,000
Young Male 10 fold increase
MVA
sports
muscle volume
Acute Compartment
Syndrome
Pathophysiology
Acute Compartment
Syndrome
Soft tissue injury
Pathophysiology
Aetiology
Crush syndrome (2)
arterial injury / revascularisation
High pressure injection
exercise
fluid infusion
arterial puncture
ruptured ganglia / cysts
Osteotomy
Snake bite
nephrotic syndrome
leukaemic infiltration
viral myosis
acute haematogenous osteomyelitis
Acute Compartment
Syndrome
coagulopathy (1)
Pathophysiology
Acute Compartment
Syndrome
Pathophysiology
Normal tissue pressure
0-4 mm Hg
8 - 10 mm Hg with exertion
Absolute compartment pressure theory
30mmHg - Mubarak and Hargens
45 mmHg - Matsen
AV gradient theory
LBF = Pa - Pv / R
<30mmHg diastolic pressure
‘do not elevate arm’
Microvascular occlusion theory
Acute Compartment
Syndrome
Tissue Survival
Muscle
3 - 4 hrs = reversible damage
6 hrs = variable damage
8 hrs = irreversible damage
Nerve
2 hrs = loose nerve conduction
4 hrs = Neuropraxia
8 hrs = irreversible damage
Acute Compartment
Syndrome
Night intern, Call from Paeds
“Dr, I think little Jimmy has
compartment syndrome”
Assessment of
Compartment Syndrome
Acute Compartment
Syndrome
Assessment
Prioritise
History
mechanism injury
intervention
analgesic requirements
Examination
Investigations
Acute Compartment
Syndrome
Diagnosis
the 6 Ps
Hargens and Mubarak
Pain out of proportion /
Passive stretch
Palpably tense
compartment
Parasthesia
Paresis
Pink skin colour
Pulse present
Acute Compartment
Syndrome
Diagnosis
Differentials
Arterial Occlusion
Peripheral nerve
injury
Muscle rupture
Acute Compartment
Syndrome
Emergent Treatment
Place at level of heart
Cut dressing or cast MUST SEE SKIN
Alert senior Dr, OR,
Anaesthetist and fast
patient
Review
Acute Compartment
Syndrome
Investigations
Radiographs
MRI USS not routine
Arterial doppler flow
Pulse Oximetry
Pressure measurements
Suspected CS
Equivocal or unreliable exam
Clinical adjunct
Acute Compartment
Syndrome
At risk Patients
Demographic
Youth
Male
Tibia fracture
High energy
Bleeding diathesis /anticoagulants
Altered Pain Perception
Altered consciousness
Regional anaesthesia
Patient-Controlled Analgesia
Central or peripheral neurological injury
Children
Associated nerve injury
Acute Compartment
Syndrome
Pressure Monitoring
Acute Compartment
Syndrome
Surgical Treatment
Indications for fasciotomy
Clinical findings
Pressure absolute above
30mmHg, or within
20mmHg Diastolic
Rising tissue pressure
>6hours of total limb
ischaemia
High risk injury
CONTRAINDICATION Missed CS 24-48hrs
Acute Compartment
Syndrome
Surgical treatment
Principles
Early diagnosis
Long extensile incision
Release all fascial
compartments
Preserve neurovascular
structures
Rigid fracture stabilisation
Debride necrotic tissues
Cover 7-10 days
Acute Compartment
Syndrome
Forearm Fasciotomy
Acute Compartment
Syndrome
Forearm Fasciotomy
Acute Compartment
Syndrome
Leg Fasciotomy
Acute Compartment
Syndrome
Leg Fasciotomy
Acute Compartment
Syndrome
Leg Fasciotomy
Acute Compartment
Syndrome
Thigh Fasciotomy
Acute Compartment
Syndrome
Foot Fasciotomy
Acute Compartment
Syndrome
Other Compartments
Hand, forearm, arm,
deltoid
Abdomen
Buttock
Acute Compartment
Syndrome
Temporary Coverage
Simple dressing
Progressive suturing
Vessel loop “Bootlace”
Vacuum Assisted
Closure
Acute Compartment
Syndrome
Definitive Coverage
Second look
Cover 7-10 days after
risk of necrotic tissue
passed
Split skin graft
Local flap
Free flap
Acute Compartment
Syndrome
Summary
Acute Compartment Syndrome
High Index of suspicion
Early diagnosis
Early intervention
Expedite time to surgery
Questions?