Compartment Syndrome
Prof. Mamoun Kremli
AlMaarefa Medical College
Pathophysiology
• Increasing volume in a closed compartment
• Pressure increased in compartment
•
Decreasing arteriovenous difference
•
Hypoxia : Muscle necrosis
Pathophysiology
Compartment pressure
N=0-4 mmHg
> 30 mmHg
Venous outflow
Venous pressure
Gradient A.V pressure
Arterial perfusion
Capillary permeability
Ischemia, tissue necrosis, edema
Pathophysiology
• Increased compartment pressure:
• ICP >30mm Hg (>40mm Hg)
• Delta Pressure: Pdiast - Pcomp < 30 mm Hg
• Related to diastolic blood pressure
• Worse in shock
Causes
• Fractures
• Bleeding in closed compartment
http://eorif.com/
• Soft tissue trauma
• Bleeding and edema in closed
compartment
http://www.hwbf.org/
• Surgery
• Post osteotomy (Tibia / Forearm)
• Circumfrential dressings / casting
• Does not allow swelling of skin
http://thehealthscience.com/
Causes
• Fractures
• Bleeding in closed compartment
http://eorif.com/
• Soft tissue trauma
• Bleeding and edema in closed
compartment
• Surgery
• Post osteotomy (Tibia / Forearm)
• Circumfrential dressings / casting
• Does not allow swelling of skin
www.pediatricsconsultant360.com
www.jointreplacementclinic.com
Clinical Picture – 5Ps
• Pain:
• Pain out of proportion of expectation
• Increased pressure / burst sensation
• Pain with passive motion / stretch
• Paresthesia
• Paralysis
TREAT
• Pallor
• Pulselessness
 too late, >8h
Clinical Picture - Look
• Shiny skin
• Pallor / or Dusky skin
• Swelling of compartment
Clinical Picture - Look
• Shiny skin
• Pallor / or Dusky skin
• Increased volume
• Blisters
• Clear fluid
• Dusky
• Bloody
• worst
Clinical Picture - Feel
• Feels tense
• Parasthesia
• Pulse ?
Clinical Picture - Move
• Pain on passive stretch
• Passive dorsiflexion of ankle (leg)
• Passive dorsiflexion of wrist (forearm)
Diagnosis
• Diagnosis is clinical:
•
•
•
•
•
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Unrelenting, bursting pain
Unreleived by analgesia
Swollen compartment
Pain on passive stretching
Sensory deficit?
Pulses always palpable
• Open fractures DO NOT necessarily
decompress an elevated compartment
pressure
Diagnosis
• Compartment pressure measurement:
• NOT a substitute for clinical diagnosis
• Invaluable in unconscious or anesthetized patients
Measuring
t
compar
pressure
• When is pressure measurement needed?
• Measure pressure only if:
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•
•
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•
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Clinical picture equivocal
Altered consciousness
Multiple injuries
Epidural anesthesia
Concomitant nerve injury
Children
Treatment
• Medical
• Surgical
Medical Management
• ABC’s.
• Correct hypotension
• Remove circumferential bandages & cast
• Limb at level of the heart
• more elevation reduces the arterial inflow
• Supplemental oxygen administration
Medical Management
• With tight cast, compartmental pressure falls:
•
•
•
•
30%  when cast is split on one side
65%  when cast is split Bilaterally
75%  with Splitting the inside padding
85 – 90%  complete removal of cast
Surgical Management
• Should not be delayed
• Fasciotomy
• Skin and All compartments
Fasciotomy
• Indications:
• High suspicion
• Equivocal clinical findings
• Significant tissue injury
• Delta pressure (DBP - compartment P.) < 25 mm Hg.
• Compartment pressure > 30mm Hg.
• S&S not resolved after 30-60min of appropriate
precautions
• Prophylactic with major corrective osteotomy of the
leg & forearm
• High risk patients
High Risk Patients
• Clinical picture equivocal
• Altered consciousness
• Multiple injuries
• Epidural anesthesia
• Concomitant nerve injury
• Children
Fasciotomy Principles
• Long extensile incisions
• Release all compartments
• Debride necrotic muscles (4C’s)
• Preserve neurovascular structures
• Never close fascia
• Keep wound open
• Repeated looks x48h, as needed
• Coverage within 7-10 days (usually within 3-5 d)
Fasciotomy Principles
Fasciotomy Principles
emedicine.medscape.com
Fasciotomy Principles
www.podiatrytoday.com
http://www.scielo.br/
Fasciotomy Principles
• Wound closure:
• Bulky dressing with a splint
• “Boot lace” vessel loop
closure
Fasciotomy Principles
• Wound closure:
• Bulky dressing with a splint
• “Boot lace” vessel loop
closure
• “V.A.C” dressing (Vacuum
Assisted Closure)
www.wjgnet.com
http://www.sjtrem.com/
Fasciotomy Principles
• Wound closure:
• Bulky dressing with a splint
• “Boot lace” vessel loop
closure
• “V.A.C” dressing (Vacuum
Assisted Closure)
• Later skin graft / flap:
• Usually skin graft
• Flap coverage needed if
nerves, vessels, or bone
exposed
mgur.com
Compartment Syndrome
• Evaluation of muscle viability (4Cs):
• Color
• Consistency
• Contractility
• Capacity to bleed
Treatment - early
•
•
•
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Color red
Consistency normal
Capable of bleeding
Contracts when pinched
✓
Treatment – late
•
•
•
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Color dark
Consistency abnormal
Not bleeding
No contractions when pinched
✗
Contraindication to fasciotomy
• Confirmed acute compartment syndrome
diagnosis for > 48 hours
• damage cannot be reversed and
• significant infection rate when dead tissue exposed
• Already dead muscles, as in crush injuries
Complications of untreated C.S.
• Volckmann’s contracture
• Muscle weakness
• Sensory loss
• Chronic pain
• Amputation
Summary
• Compartment syndrome is a clinical diagnosis
• Should not be missed - Disaster
• Requires urgent treatment
• “Time” is the most important factor to avoid
irreversible complications
• Do NOT apply circumferential dressings