2 November 2017 Compartement Syndrome

Compartement Syndrome
ZT/JA/WM/KY
Moderator: VC
Supervisor: dr. Henry Yurianto M.Phil, PhD, Sp.OT(K)
02 November 2017
McQueen MM. Acute Compartement Syndrome. In: Bucholz et al. Rockwood & Greens fractures in Adults 7th ed.
Etiology
Conditions Associated with Injury Causing Less Common Causes of Acute Compartment
Acute Compartment Syndrome Presenting Syndrome
to an Orthopaedic Trauma Unit
Conditions Increasing the Volume of Compartment Contents
Fracture
Underlying Condition % of Cases Soft tissue injury
Tibial diaphyseal fracture 36 Crush syndrome (including use of the lithotomy position)90
Soft tissue injury 23.2 Revascularization
Exercise79
Distal radius fracture 9.8 Fluid infusion (including arthroscopy)10,129
Crush syndrome 7.9 Arterial puncture130
Diaphyseal fracture forearm 7.9 Ruptured ganglia/cysts29
Osteotomy43
Femoral diaphyseal fracture 3.0 Snake bite145
Tibial plateau fracture 3.0 Nephrotic syndrome139
Hand fracture(s) 2.5 Leukemic infiltration144
Viral myositis76
Tibial pilon fractures 2.5 Acute hematogenous osteomyelitis137
Foot fracture(s) 1.8 Conditions Reducing Compartment Volume
Ankle fracture 0.6 Burns
Repair of muscle hernia4
Elbow fracture dislocation 0.6 Medical Comorbidity
Pelvic fracture 0.6 Diabetes20
Humeral diaphyseal fracture 0.6 Hypothyroidism65
Bleeding diathesis/anticoagulants63
Introduction
Pathophysiology
local trauma and soft tissue destruction > bleeding
and edema > increased interstitial pressure > reduced
microvascular perfusion > macrovascular arterial
occlusion > myoneural ischemia
Swelling and ultimate loss of viability of a muscle
group, is caused by compromised circulation
within a confined anatomic space
anterior tibial compartment of the leg, the volar
compartment of the forearm, or the interosseous
compartments of the hand
Moore D. Compartement Syndrome. In: Orthobullets.com.
Bullough PG. The Effects of Injury and the Inflammatory Response. In Orthopaedic Pathology 5th ed. 2010.
Introduction
Vascular occlusion from either direct injury or
increased pressure within the anatomic compartment
> diminished tissue viability and function.
Pain and swelling are prominent symptoms.
Muscle necrosis > original tissue is replaced by dense,
fibrous connective tissue, with subsequent deformity
and loss of function.
Microscopic findings depend on the stage at which the
tissue is obtained.
Muscle necrosis, granulation, scar tissue, and calcification
may be present
Etiology of Compartement Syndrome
Thompson JC. Basic Science. In: Netters Concise Orthopaedic Anatomy 3rd ed. 2010
Introduction
Special considerations
vascular injuries treated with revascularization
revascularization of a previously ischemic limb leads to swelling and
intracomparmental hypertension
consider prophylactic fasciotomies following all repairs of traumatic vascular
injuries
pedriatrics
children are unable to verbalize feelings
if suspicious then perform compartment pressure measurement under
sedation
increasing pain medication requirement and pain out of proportion to injury is
the most sensitive clinical sign
functional outcome is inversely related to the duration of elevated tissue
pressures before surgical decompression
hemophiliacs
give Factor VIII replacement before measuring compartment pressures

Tissue Pressure Measurements
Indications:
Polytrauma Patient
Ass. HI, intoxication, ETT interfere HT and PE
Low Diastolic Pressure
Px with chemical overdose/ HI and Isolated Long
Bone Fracture
Difficult assess HT & PE
Inconclusive Clinical Diagnosis
Amendola A and Twaddle BC. Compartement
Syndromes. In: Browner BD, Jupiter JB , Levine
AM and Trafton PG [eds.]. Skeletal Trauma:
Basic Science, Managmenet and Recosntruction
3rd ed. 2003.
Measurement Techniques
Needle Manometer
Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG
[eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
Continuous Infusion Technique
Low accuracy: tissue compliance << when
pressure greater than 30 mmHg artifically high
reading
Wick Catheter
Polyglycolic acid suture
pulled into tip of piece
of PE60 polyethylene
tubing
Catheter placement
sleeve + wick catheter
connected to pressure
transducer & recorder
introduced through
a large trocar. Needle is
withdrawn & catheter
is taped to the skin
Slit Catheter
PE60 Polyethylene tubing with
five 3-mm slits in the end of tube
Slit Catheter System
Microcappilary Infusion
Arterial Transducer
Measurement
Noninvasive Techniques (Chronic
CS)
Tc 99m-MIBI Scintigraphy
Laser Doppler Flow
Near-Infrared Spectroscopy
Arm Compartement Syndrome
2 Compartment:
Anterior Compartment
Anterior: Brachial fascia
Medial / lateral: intermusc
Septa
Post: humerus
Posterior Compartment
Same as anterior but lies
posterior to humerus
Compartments of the Arm, Their Contents, and
Clinical Signs of Acute Compartment Syndrome
Compartment Contents Signs
Anterior Biceps Radial nerve (distal third)
Brachialis Pain on passive elbow extension
Coracobrachialis Numbnessmedian/ulnar
Median nerve distribution
Ulnar nerve Numbnessvolar/lateral distal
Musculocutaneous nerve forearm
Lateral cutaneous nerve Weaknesselbow flexion
Antebrachial nerve Weaknessmedian/ulnar
motor function
Posterior Triceps Pain on passive elbow flexion
Radial nerve Numbnessulnar/radial
Ulnar nerve (distally) distribution
Weaknesselbow extension
Weaknessradial/ulnar motor
function
Forearm Compartment Syndrome
Relatively rare
Associated with direct blow or crushing component
Forearm: 3 osseofacial compartment (superficial
flexor, deep flexor, extensor) Henrys approach
volar flexor volar ulnar
approach / volar (henrys)
approach
Dorsal thompson
exposure
A straight incision from the lateral
epicondyle to the midline of the
wrist is used
Interval ECRB and EDC
Compartments of The Forearm, Their Contents,
and Signs of Acute Compartment Syndrome
Volar Flexor carpi radialis longus and Pain on passive wrist/finger
brevis extension
Flexor digitorum superficialis and Numbnessmedian/ulnar
profundus distribution
Pronator teres Weaknesswrist/finger flexion
Pronator quadratus Weaknessmedian/ulnar motor
Median nerve function in hand
Ulnar nerve
Dorsal Extensor digitorum Painpassive wrist/finger
Extensor pollicis longus flexion
Abductor pollicis longus Weaknesswrist/finger flexion
Extensor carpi ulnaris
Mobile wad Brachioradialis Pain on passive wrist
Extensor carpi radialis flexion/elbow extension
Weaknesswrist
extension/elbow flexion
Forearm Compartment Syndrome
Henrys approach
midforearm
Volar Ulnar approach Dorsal approach
Hand Compartment Syndrome
Introduction
Volkman's ischemic contracture is a posttraumatic contracture of the
wrist, hand, and forearm
FDP and FPL are most commonly affected
Interossei
Physical exam
diagnosis based primarily on physical exam in patient with intact
mental status
pain with passive stretch of fingers (intrinsic muscle) and Instrinsic
paralysis
Compartment pressure measurement
indicated in patients with altered mental status
absolute value of 30 mm Hg is indicator of fasciotomy
use threshold of 20 mm Hg in hypotensive patient
Thompson JC. Hand In: Netters Concise Orthopaedic Anatomy 3rd ed. 2010
Thigh Compartment Syndrome
Three muscle compartments: quadriceps, hamstrings
and adductors
Can be due to IM Nailing
Quadriceps compartment
Anterolateral incision (Q)
Splitting iliotibial band
fascia overlying vastus lateralis is divided along its length
Intermuscular septum (H)
Separate longitudinal incision along its length
(A)
Compartments of the Thigh, Their Contents, and
Signs of Acute Compartment Syndrome
Anterior Quadriceps muscles Pain on passive knee flexion
Sartorius Numbnessmedial leg/foot
Femoral nerve Weaknessknee extension
Posterior Hamstring muscles Pain on passive knee extension

Sciatic Nerve Sensory changes rare
Weaknessknee flexion
Adductor Adductor muscles Pain on passive hip abduction

Obturator nerve Sensory changes rare
Weaknesship adduction
Medial compartment
Leg Compartment Syndrome
Introduction
occur in 1-10% of
tibial shaft fractures
crush injuries
Physical exam
mental status
pain out of proportion to injury
pain with passive stretch of ankle or toes (most reliable test)
tense lower extremity
pulses (presence of pulses is not a reliable factor for excluding the
diagnosis)
sensory or motor nerve deficits
isolated lateral compartment compartment syndrome would only affect
superficial peroneal nerve

absolute value of 30 to 45 mm Hg or
within 30 mm Hg of diastolic BP (delta p)
if delta p is less than 30 mmHg intraoperatively, check
preoperative diastolic pressure and follow postoperatively as
intraoperative pressures may be low and misleading

Compartments of the Leg with Their Contents and
Clinical Signs of Acute Compartment Syndrome in Each
Anterior Tibialis anterior Pain on passive flexion
Extensor digitorum longus ankle/toes
Extensor hallucis longus Numbness1st web space
Peroneus tertius Weaknessankle/toe flexion
Deep peroneal (anterior tibial)
nerve and vessels
Lateral Peroneus longus Pain on passive foot inversion
Peroneus brevis Numbnessdorsum of foot
Superficial peroneal nerve Weakness of eversion
Superficial posterior Gastrocnemius Pain on passive ankle extension
Soleus Numbnessdorsolateral foot
Plantaris Weaknessplantar flexion
Sural nerve
Deep posterior Tibialis posterior Pain on passive ankle/toe
Flexor digitorum longus extension/ foot eversion
Flexor hallucis longus Numbnesssole of foot
Posterior tibial nerve Weaknesstoe/ankle flexion,
foot inversion
Treatment
initial treatment for swelling or pain that is NOT
compartment syndrome involves bi-valving the
cast and loosening circumferential dressings
emergent fasciotomy of all four compartments
if untreated for 8 hours irreversible myoneural necrosis
and fibrosis will occur
15-18 cm incision required for adequate decompression

two methods
dual medial-lateral incisions
elevation of the soleus must be done via medial
approach to access deep posterior compartment
single lateral incision
common peroneal nerve at risk with proximal
dissection
superficial peroneal nerve at risk with distal
dissection
postoperative dressing changes followed by delayed
primary closure or skin grafting at 3-7 days post
decompression
hyperbaric oxygen therapy
works by increasing the oxygen diffusion gradient
Three Techniques:
Fibulectomy
Unnecessary & too radical
Perifibular fasciotomy
Single lateral incision
Head of fibula distally to ankle
Retract intermuscular septum (anterior / lateral)
protect superficial peroneal nerve
Fasciotomy: 1 cm in front of intermuscular septum (ant
compartment) and 1 cm posterior (lateral compartement)
Double-incision Technique
Amendola A and Twaddle BC.
Compartement Syndromes. In: Browner
BD, Jupiter JB , Levine AM and Trafton
PG [eds.]. Skeletal Trauma: Basic Science,
Managmenet and Recosntruction 3rd
ed. 2003.
Three Techniques:
Fibulectomy
Perifibular fasciotomy
Double-incision Technique
Bridge of skin at least 8 cm
1st: knee to ankle (between anterior / lateral
compartment)
Care of superficial peroneal nerve
2nd: 1-2cm behind posteromedial border of the tibia
Care of saphenous vein and nerve
Foot Compartment Syndrome
Introduction
higher incidence with
calcaneal fxs
Lisfranc complex injuries
crush injuries
open injuries have a higher incidence than closed fractures
Physical exam
mental status
pain out of proportion to injury
pain with dorsiflexion of toes (places intrinsic muscles on stretch)
tense swollen foot
pulses (presence of pulses is not a reliable factor for excluding the
diagnosis)
absolute value of 30 to 45 mm Hg or
within 30 mm Hg of diastolic BP (delta p)
if delta p is less than 30 mmHg intraoperatively, check
preoperative diastolic pressure and follow postoperatively as
intraoperative pressures may be low and misleading

Treatment
emergent foot fasciotomy
9 major compartments of foot have been described
medial (Intrinsic muscles of the great toe)
Lateral (Flexor digiti minimi & Abductor digiti minimi)
interosseous (x4) - Interosseous muscles & Digital nerves
central (x3: superfical - Flexor digitorum brevis, middle -
Adductor hallucis, and deep/Calcaneal - Quadratus plantae)
posterior tibial neurovascular bundle and quadratus
plantae are in the deep central compartment
surgical technique
dual dorsal incisons (gold standard)
dorsal medial incision
allows decompressin of 1st and 2nd interosseous (lateral),
medial, and deep central compartments
dorsal lateral incison
allows decompression of 3rd and 4th interosseous
(lateral), superfical central, middle and central)
some add an additional medial incision
single medial incision
has been described but is technically more difficult

Complications
Delay to fasciotomy of more than 6 hours is
likely to cause significant sequelae
muscle contractures
muscle weakness
sensory loss
Infection
nonunion of fractures
In severe cases amputation may be necessary
because of infection or lack of function
Pathology
Pathology
QUESTIONS
Q1
A 28-year-old male sustains a midshaft fibula fracture after
being kicked during a karate tournament and develops
compartment syndrome isolated to the lateral
compartment of his leg. If left untreated, which of the
following sensory or motor deficits would be expected?
1. Decreased sensation on the dorsum of his foot involving

the hallux, 3rd, and 4th toes
2. Inability to plantar flex the ankle
the first webspace
4. Inability to dorsiflex the ankle
5. Inability to abduct his toes
Q1
A 28-year-old male sustains a midshaft fibula fracture after
being kicked during a karate tournament and develops
compartment syndrome isolated to the lateral
compartment of his leg. If left untreated, which of the
following sensory or motor deficits would be expected?

the hallux, 3rd, and 4th toes
2. Inability to plantar flex the ankle
the first webspace
4. Inability to dorsiflex the ankle
5. Inability to abduct his toes
PREFERRED RESPONSE 1
DISCUSSION: The clinical vignette describes a scenario of isolated
compartment syndrome in the lateral compartment of the leg. The
only nervous structure residing in the lateral compartment is the
superficial peroneal nerve. In compartment syndrome of the lateral
leg compartment, failure of prompt surgical fasciotomy would
present as a sensory deficit of the superficial peroneal nerve
presenting as numbness on the dorsum of his foot involving the
hallux, 3rd, and 4th toes, as seen in Illustration A.
Matsen et al discuss the poor results which can be a cause of late
diagnosis and surgical decompression. They recommended
compartment monitoring in equivocal cases as well as release of all
four leg compartments when facing leg compartment syndrome. A
diagram of a two-incision fasciotomy is shown in Illustration B.
Olson et al provide a review of compartment syndrome for the
lower extremity. They discuss a variety of injuries and medical
conditions may initiate acute compartment syndrome, including
fractures, bleeding disorders, and other trauma. Although the
diagnosis is primarily a clinical one, they also recommend
supplementation with compartment pressure measurements in
equivocal cases.
Q2
During a dual incision fasciotomy of the leg, the soleus
is elevated from the tibia to allow access to which of
the following compartments?
1. Superficial posterior
2. Deep posterior
3. Lateral
4. Anterior
5. Mobile wad
Q2
During a dual incision fasciotomy of the leg, the soleus
is elevated from the tibia to allow access to which of
the following compartments?
1. Superficial posterior
2. Deep posterior
3. Lateral
4. Anterior
5. Mobile wad
DISCUSSION: The soleus is elevated/released
from the posterior tibia during the medial
approach to allow access to the deep posterior
compartment. Release of this compartment
cannot be done without proper elevation of the
soleus. The superficial posterior compartment
mass is primarily located in the proximal half of
the leg, while the deep posterior musculature is
located in the distal 2/3 of the leg.
Q3
A 35-year-old female presents to the
emergency room after a motor vehicle collision
where her leg was pinned under the car for
over 30 minutes. A clinical photo and
radiographs are shown. Which of the following
is the most accurate way to diagnose
compartment syndrome?
1. surgeon's palpation of the leg compartments

2. parathesias in her foot
3. diastolic blood pressure minus intra-
compartmental pressure is less than 30 mmHg
compartmental pressure is greater than 30
mmHg
5. intra-compartmental pressure measurement
of 25 mmHg
Q3
A 35-year-old female presents to the
emergency room after a motor vehicle collision
where her leg was pinned under the car for
over 30 minutes. A clinical photo and
radiographs are shown. Which of the following
is the most accurate way to diagnose
compartment syndrome?
1. surgeon's palpation of the leg compartments

2. parathesias in her foot
compartmental pressure is less than 30 mmHg
compartmental pressure is greater than 30
mmHg
5. intra-compartmental pressure measurement
of 25 mmHg
DISCUSSION: The clinical picture is consistent with compartment
syndrome. The most accurate way to make the diagnosis is to
measure the difference between the diastolic blood pressure and
intracompartmental pressure (delta p). In a prospective study of
116 patients with tibial diaphyseal fractures, McQueen et al found
that the use of a differential pressure of 30 mmHg as a threshold
for fasciotomy led to no missed cases of acute compartment
syndrome. They recommended that a fasciotomy should be
performed if the differential pressure level drops to under 30
mmHg. The cited study by Kakar et al found the intraoperative DBP
is significantly lower than the preoperative DBP in patient
undergoing IM nailing for tibia shaft fractures. Therefore, they
emphasize that the surgeon should recognize that intraoperative
DeltaP may be lower than DeltaP once the patient is awakened in
deciding whether to perform a fasciotomy versus awaken the
patient and perform serial examinations and or compartment
pressure measurements. An absolute intra-compartmental value
greater than 30 to 45mmHg can also be used to make the diagnosis
of compartment syndrome, but is more controversial than the delta
p according to Kakar and Amendola.
Q4
A 32-year-old male sustains the injury
seen in Figure A. His blood pressure
preoperatively was 132/84. After
closed reduction and placement of an
intramedullary nail, his intraoperative
leg compartment pressures are
measured, with the highest being 28
mmHg. His blood pressure at this time
is 84/57. What is the next appropriate
step?
1. Immediate four compartment
fasciotomy
2. Fasciotomy of the highest
compartment(s)
3. Acute shortening of the tibia with
exchange of nail as needed
4. Repeat evaluation and compartment
pressure evaluation in recovery room
5. Addition of pressors to anesthesia
Q4
A 32-year-old male sustains the injury
seen in Figure A. His blood pressure
preoperatively was 132/84. After
closed reduction and placement of an
intramedullary nail, his intraoperative
leg compartment pressures are
measured, with the highest being 28
mmHg. His blood pressure at this time
is 84/57. What is the next appropriate
step?
1. Immediate four compartment
fasciotomy
2. Fasciotomy of the highest
compartment(s)
3. Acute shortening of the tibia with
exchange of nail as needed
4. Repeat evaluation and compartment
pressure evaluation in recovery room
5. Addition of pressors to anesthesia
DISCUSSION: Figure A shows a mildly comminuted tibia fracture,
which is a fracture highly associated with compartment syndrome.
However, in this scenario, the delta p (difference between
compartmental pressures and diastolic pressure) is greater than 30
preoperatively, with a decrease to less than 30 intraoperatively, due
to the hypotension associated with anesthesia. The referenced
article by Kakar et al notes that the delta p may be spuriously low
intraoperatively, and with tibial nailing, it is safe to assume the delta
p will return to a higher level postoperatively. They recommended
continued monitoring in the postoperative period with clinical
examination and measurements as needed. The McQueen
referenced article showed that the delta p is more important than
absolute pressures, as an absolute threshold of 30mmHg would
have led to unnecessary fasciotomies in 43% of their cohort.
Q5
A 10-year-old girl is treated for a tibia/fibula fracture with a
long leg cast. The on-call resident is called to evaluate the
patient for increasing pain medicine requirements and
tingling in her foot. Examination of the cast reveals that the
ankle has been immobilized in 10 degrees of dorsifelxion.
What ankle position results in the lowest deep posterior
calf compartment pressures in a casted leg?
1. 40-50 degrees of plantar flexion

2. 10-20 degrees of ankle dorsiflexion
3. Neutral to 30 degrees of plantar flexion
4. Neutral to 10 degrees of dorsiflexion
5. Ankle position has no effect on calf compartment
pressure
Q5
A 10-year-old girl is treated for a tibia/fibula fracture with a
long leg cast. The on-call resident is called to evaluate the
patient for increasing pain medicine requirements and
tingling in her foot. Examination of the cast reveals that the
ankle has been immobilized in 10 degrees of dorsifelxion.
What ankle position results in the lowest deep posterior
calf compartment pressures in a casted leg?
1. 40-50 degrees of plantar flexion

2. 10-20 degrees of ankle dorsiflexion
3. Neutral to 30 degrees of plantar flexion
4. Neutral to 10 degrees of dorsiflexion
5. Ankle position has no effect on calf compartment
pressure
DISCUSSION: Agitation, anxiety, and increasing analgesic
requirments are the "3 A's" of pediatric compartment syndrome.
Weiner et al measured intramuscular compartment pressure in the
anterior and deep posterior compartments of the leg in seven
healthy adults who had long leg casts placed. They found that in a
casted leg the intramuscular pressure in the anterior compartment
was lowest with the ankle in neutral, and the deep posterior
compartments was lowest when the ankle joint was in the resting
position, approximately 37 degrees of plantar flexion. Based on this,
they concluded that the safest ankle casting position regarding
compartment pressure is between 0 and 37 degrees of plantar
flexion. After the cast was bivalved, they noted a significant
decrease in intramuscular pressure of 47 per cent in the anterior
compartment and of 33 per cent in the deep posterior
compartment. Constrictive casts and abberant ankle positioning can
exacerbate pain/symptoms. Loosening of the cast by bivalving,
spreading, and cutting underlying stockinette/softroll should always
be the first step in management of possible compartment
syndrome.
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2 November 2017 Compartement Syndrome

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2 November 2017 Compartement Syndrome

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Compartement Syndrome

Moore D. Compartement Syndrome. In: Orthobullets.com.

Posterior Hamstring muscles Pain on passive knee extension

Adductor Adductor muscles Pain on passive hip abduction

Moore D. Compartement Syndrome. In: Orthobullets.com.

Moore D. Compartement Syndrome. In: Orthobullets.com.

Moore D. Compartement Syndrome. In: Orthobullets.com.

Moore D. Compartement Syndrome. In: Orthobullets.com.

Moore D. Compartement Syndrome. In: Orthobullets.com.

1. Decreased sensation on the dorsum of his foot involving

1. Decreased sensation on the dorsum of his foot involving

1. surgeon's palpation of the leg compartments

1. surgeon's palpation of the leg compartments

1. 40-50 degrees of plantar flexion

1. 40-50 degrees of plantar flexion

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