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COMPARTMENT

SYNDROME(S)

Christian Dumontier, MD, PhD


Centre de la Main, FWI, Guadeloupe

Presentation and some references can be downloaded at


www.diuchirurgiemain.org
COMPARTMENT SYNDROMES

• Acute compartment
syndrome

• « Volkmann’s
syndrome »

• Chronic exertion
syndrome: mostly sport
induced
HISTORICAL REVIEW
• Richard von Volkmann described the conditions of
irreversible contractures of the flexor muscles of the hand
because of ischemic processes occurring in the forearm.

• Hildebrand (1906) was the first to suggest that elevated


tissue pressure may be related to ischemic contracture.

• Bardenheuer (1906) suggested that surgical


decompression (fasciotomy) of the forearm fascia might
be a method of treatment.

Volkmann R. Die ischaemischen Muskellahmungen and Kontrakturen. Zentralbl Chir. 1881;8:801–3.


Hildebrand O. Die Lehre von den ischaemische Muskellahmungen und Kontrakture. Samml Klin Vortrage 122:437, 1906.
Bardenheuer B. Die ischämische Kontraktur und Gangrän als Folge der Arterienverletzung. Leuthold’s Gedenkschrift 1906; 2:87.
MAIN CAUSES OF COMPARTMENT SYNDROMES

• Fractures (long bones): 75% of ACS (mostly tibial #)


• DRF in adults (0,25% risk) or forearm # (3,2% risk),
supracondylar in children - 18% in forearm ACS
• Soft-tissue injury (23% in Forearm)
• Crush injuries Mostly young
• Burns males < 35 yrs
• Snake or insect bites
• Intracompartmental haemorrhage
• Reperfusion injuries (perform fasciotomies if limb ischemia > 6 h)
• Prolonged limb compression (poor positioning, unconscious patients)
Kalyani BS et al. Compartment Syndrome of the Forearm: A Systematic Review. J Hand Surg 2011;36A:535–543.
PATHOPHYSIOLOGY
Hematoma due to Increase
Too tight bandage or cast
fracture, anticoagulation, pressure Extravasation of perfusion
direct trauma,
Tourniquet
hemophilia

Prolonged
pressure in
comatous
patients
PATHOPHYSIOLOGY

Diminution
of muscle
perfusion

Tourniquet
Arterial injury
PATHOPHYSIOLOGY

Muscular
(and nerve)
ischemia
PATHOPHYSIOLOGY

extravasation
of cellular fluid
= oedema
Increase pressure
Decreased
AV
pressure
gradient
PATHOPHYSIOLOGY
Increase
pressure

extravasation Diminution
of cellular fluid of muscle
= oedema perfusion

Muscular
(and nerve)
ischemia
Increase
pressure

extravasation Diminution
of cellular fluid of muscle
= oedema perfusion

Muscular
(and nerve)
ischemia

Death of muscles +/- nerves of the compartment = Volkmann’s syndrome


GOALS OF TREATMENT
extravasation Increase
of cellular fluid pressure
= oedema Diminution
of muscle
perfusion

Break the vicious circle as early as


possible by opening the involved
compartment
68% normal if performs within 12 hours vs 8% if > 12 hours Muscular
Complication rate 4,5 % within 12 hours vs 54% if > 12 hours (and nerve)
ischemia

Vaillancourt C et al. Acute compartment syndrome: how long before muscle necrosis occurs? CJEM 2004;6(3):147–54
Sheridan GW, Matsen FA. Fasciotomy in the treatment of the acute compartment syndrome. JBJS Am 1976;58:112–5.
HOW TO MAKE AN EARLY DIAGNOSIS ?

• Think of it ! be afraid of it !

• Physical examination

• Ancillary tools

Bhattacharyya T, Vrahas MS. The medical-legal aspects of compartment syndrome. J Bone Joint Surg Am 2004;86-A:864–
PHYSICAL EXAMINATION: THE 6 P’S RULE
• Pain:
• Out of proportion
• « Crescendo pain », nor responsive to
analgesia
• On passive stretch of the muscles within
the compartment
• Paresthesiae (loss of sensation is a late
sign)
• Paralysis (late sign - muscle weakness is
more sensitive)
• Pallor:
• Pulselessness (very late sign)
• Poikilothermia : affected limb feels cooler Independently each sign
has a poor prognostic
value (< 20%)
Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma 2002;
16: 572-7.
Griffiths DL. Volkmann’s ischaemic contracture. Br J Surg 1940; 28:239 –260.
FOR HAND COMPARTMENT SYNDROME

• Cadaveric model (3 cases - 17 surgeons tested)

• Thenar eminence:

• Digital palpation: Se 49%, Sp 79%, PPV 86%, NPV 37%

• Manometer: Se 97%, Sp 86%, PPV 95%, NPV 92%

• Hypothenar eminence:

• Digital palpation: Se 62%, Sp 83 %, PPV 92%, NPV 40%

• Manometer: Se 100%, Sp 100%, PPV 100%, NPV 100%.


Wong JC et al. Accuracy of Measurement of Hand Compartment Pressures: A Cadaveric Study. J Hand Surg Am. 2015;40(4):
701-706
PHYSICAL EXAMINATION IN DIFFICULT CASES

• Unconscious patient: Torso

• Tense compartment,

• Phlyctenulae in mirror,

• In children:

• Anxiety + increasing
analgesic requirement is a
very reliable indicator of
compartment syndrome.

Hand
PRESSURE MEASUREMENTS
• Absolute pressure: threshold is 30 mm
Hg

• Delta pressure = diastolic blood


pressure - compartment pressure
(Fasciotomy is indicated if < 30 mmHg)

• Continuous pressure monitoring may


increase or decrease the rate of
fasciotomy according to series.

• Blood tests ? MRI ? Ph ? laser Doppler


flowmetry 99Tcm-methoxy-isobutryl
,

isonitril scintigraphy ? ☛ No

Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop
Relat Res 1975; 113: 43-51.
McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br
1996; 78: 99-104
LIMITATIONS
• 38 physicians

• Correct technique only 31% of the


time,

• 30% of the measurements were


associated with a “catastrophic” error.

• When the correct technique was


used, only 60% of the measurements
were accurate,

Large TM, Agel J, Holtzman DJ, et al. Interobserver variability in the measurement of lower leg compartment pressures. J Ortho
Trauma 2015;316–21.
TREATMENT
• Protective measures:

• Hand elevation (heart level, not


above) and hourly evaluation

• Restoring normal blood pressure

• Removal of constricting dressings

• Supplemental oxygen administration.

• Surgical release of involved


compartments whenever
compartment syndrome is
suspected
WHEN IT IS TOO LATE TO RELEASE THE
COMPARTMENT ?

• After 48 hours of ischemia, the pathological


pressure begins to decrease spontaneously
because of muscle necrosis.

• Delayed cases >24 h may not be treated because


of the risk of septicemia, kidney failure, cardiac
arrhythmia and eventually death.
Lagerstrom CF, Reed RL, 2nd, Rowlands BJ, Fischer RP. Early fasciotomy for acute clinically evident posttraumatic compartment
syndrome. Am J Surg. 1989;158:36–9
Giladi AM, Chung KC. Fasciotomy for Compartment Syndrome of the Hand and Forearm.
Operative Techniques: Hand and Wrist Surgery, Chung KC (ed) 3rd ed, 2018, Elsevier
HAND AND FINGERS COMPARTMENTS

• 10 compartments at the hand

• Thenar, hypothenar,
adductor pollicis, dorsal
interosseous (n = 4), volar
interosseous (n = 3).

• Digital compartments (bound


by Cleland ligament and
Grayson ligaments), has also
been described in burned
patients
VOLAR INCISIONS FOREARM
• No tourniquet

• Two incisions if both volar and dorsal compartment releases


are required. SKIN incision is needed

• The volar incision is used to decompress the volar and mobile


wad compartments.

• S-type incision includes carpal tunnel release distally and the


ulnar side of the elbow flexion crease proximally.

• Incision begins and ends along the ulnar border of forearm and
is located along the radial border of mid forearm.

• Proximally, identify and divide the lacertus fibrosis; protect


the underlying brachial artery and median nerve.

• Longitudinally incise the fascia overlying the flexor carpi


ulnaris.

• Expose the deep compartment of the forearm by the


retracting flexor carpi ulnaris ulnarly and the flexor
digitorum superficialis laterally.

• Longitudinally incise the fascia overlying the deep muscles


of the forearm.
VERY IMPORTANT
• The more severe lesions are
in the middle of the muscle
belly

• Incise fascia/epimysium
longitudinally if muscles look
pale and tense after
fasciotomy

• Muscles centered around


anterior interosseous artery
are mostly affected—FPL, FDP.

Chandraprakasam T, Kumar RA. Acute compartment syndrome of forearm and hand. Indian J Plast Surg. 2011; 44(2): 212–218.
TECHNICAL DIFFICULTIES

• Due to the intense tension,


tendons and/or nerves are
frequently exposed after
release.

• Dorsal incision may not be


needed

Chan PSH, Steinberg DR, Pepe MD, Beredjiklian PK. The significant of the three volar spaces in forearm compartment syndrome:
A clinical and cadaveric correlation. J Hand Surg 1998;23A:1077–81.
Nwakile I et al. A single volar incision fasciotomy will decompress all three forearm compartments: A cadaver study. Injury
2012;43:1949–1952
DORSAL INCISIONS
• Proximal landmark is approximately 4 cm
distal to the lateral epicondyle.

• Distal landmark is the middle of the wrist.

• 10 cm longitudinal skin incision.

• Incise the fascia overlying the extensor


digitorum communis muscle.

• Identify and dissect the interval between


the extensor digitorum communis and the
extensor carpi radialis muscles to access
the deep fascia.

• Incise the deep fascia longitudinally over


the deep dorsal compartment muscles.
POST-PROCEDURE ?
• Limb elevation 24-48 h.

• Dressing changes at the bedside or in the


OR.

• If necrotic muscle develops ☛ excision of


necrotic muscle.

• Delayed primary skin closure when swelling


subsides.

• If skin closure cannot be performed within 5


days, perform split-thickness skin grafting.

• VAC can be used (no benefit)


Asgari MM, Spinelli HM. The vessel loop shoelace technique for closure of fasciotomy wounds. Ann Plast Surg. 2000;44:225–9.
Wood J, Genova R, Walsh JJ. Compartment syndrome. Medscape, Updated: Dec 14, 2017
Kakagia D, Karadimas EJ, Drosos G, et al. Wound closure of leg fasciotomy: comparison of vacuum- assisted closure versus
shoelace technique. A randomised study. Injury 2014;45(5):890–3.
HAND FASCIOTOMIES

• 4 incisions can be used

• Dorsal incisions are the most important


OUTCOMES
• In children:

• Excellent long-term outcomes in 17 (74%) - Fair in 5 (22%)


(motor function, stiffness, or decreased sensation)

• In adults:

• 13/17 had normal hand function (hand compartment syndrome

• 8 /16 had normal recovery (forearm compartment syndrome)

Kanj WW, Gunderson MA, Carrigan RB, et al. Acute compartment syndrome of the upper extremity in children: diagnosis,
management, and outcomes. J Child Orthop 2013;7(3):225–33.
Brostom LA, Stark A, Svartengren G. Acute compartment syndrome in forearm fractures. Acta Orthop Scand 1990;61: 50-53.
Ouellette EA, Kelly R. Compartment syndrome of the hand. J Bone Joint Surg 1996;78A:1515-1522.
IF UNTREATED ?

• Neurological deficit (21%


forearm ACS),

• Muscle necrosis,

• Ischaemic contracture,

• Infection,

• Delayed fracture union

Kalyani BS, Fisher BE, Roberts CS, et al. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am 2011;36(3):
535–43.
CONCLUSION
• Early diagnosis ☞ Think of it

• Evaluate intra-compartment pressure if


any doubt

• No one will condemn you for opening a


compartment, even if unnecessary 🤨

• Everyone will condemn you for not


opening it if it was necessary ! 🤬 🤑