Compartment

Syndrome
By NSHIMIYIMANA ALEXIS
 Outline

 Definition & Pathophysiology

 Epidemiology
 Clinical presentation
 Diagnosis
 Management & Prognosis

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 Definitions
o Compartment Sd:
Devastating condition where interstitial pressure in a
closed osteo-fascial compartment rises to a level that
decreases perfusion (pTissue> pVein)

May lead to irreversible muscle and nerve damage if no

prompt management
o Acute compartment sd (ACS):
– due to severe injury
– medical emergency

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o Chronic compartment sd (CCS):
– due to exertion,
– ceases when activity is stopped (within 5 min)
– common in Anterior lower leg compartment also
seen in forearms of motorunners
– Unclear pathophysiology--- repetitive muscle
contractions(elevated resting pressure)-- < arterial
supply ---ischemia

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 Pathophysiology
o Common causes:
– Fractures
– Post trauma hemorrhage and edema, crush injury
– Internal bleeding (hemophilia patients)
– Venomous toxins from insect and animal bites resulting
in extensive tissue swelling
– Iatrogenic: Tight dressings, tight fitting casts, and intra-
arterial infiltration(drugs or sclerosing agents),
extravasation of IV fluids, etc.
– Eschar from burn wounds
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A continuous increase in pressure occurs until the low
intramuscular arteriolar pressure is exceeded and
blood cannot enter the capillaries

Whiteside' Theory
Development of compartment syndrome depends on:
• MPP = DBP(Diastolic BP) –ICP(Intra-compartment
Pressure)
• Muscle perfusion pressure(MPP) < 30 mmHg Tissue
hypoxia
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 Hypoxia----ischemia----then myocytes secrete
histamine like substances, increase of capillary
permeability—more edema
 Myocyte lysis(usually resist up to 3h)—release
of proteins, osmotically active—more edema
 More pressure --- vascular occlusion—
compartment temponade

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 Vicious cycle to break

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 The vicious cycle of Volkmann's ischemia

Increased ICP
o Increases local venous P
o Narrowed AV perfusion gradient
o Compartment tamponade

Decreased capillary blood

flow
o Oxygen deprivation
o Local tissue necrosis
o Nerve injury and muscle ischemia
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 Muscle ischemia
o 4 hours - reversible damage
o 4-8 hours – variable
o 8 hours – irreversible changes
Myoglobinuria – 23% of cases, McQueen MM et al.
o Renal failure
Nerve ischemia
o 1 hour - normal conduction
o 1- 4 hours - neuropraxic damage reversible
o 8 hours - axonotmesis and irreversible change

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 Epidemiology and risk factors
• More in men < 35 years (larger muscle mass & likelihood of high
energy trauma)
– Mean age: M= 30 y, F=44y
• Men are ten times more involved than females

• Involve long bone fractures: 75% of ACS

• Tibial diaphysis (38%), most common followed by Distal radius (9.8%),
McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg
Br 2000; 82:200.

– But also can occur in hands, foot, buttocks,…

• Annual incidence: 0.7 (F) to 7.3(M)/100,000 people, Allison M. et al. PMC

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• Overall: up to 5% of tibia fractures, 3% of forearm fractures (0.25%
radius), the rate increase if comminuted.

• 18% of forearm ACS are due to fractures and 23% to soft tissue
injuries without fractures, Elliot et al.

• Grottkau et al. found

that forearm fractures were actually more
associated with ACS than supracondylar (74% vs. 15%), # from
previous beliefs

• ACS without fractures has been associated with delayed diagnosis

and greater rates of muscle necrosis(20% vs 8 %) (upto date)

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 Clinical presentation
ACS begins as a tense, painful limb---suggestive

Symptoms of ACS can include the following:

– Pain out of proportion to apparent injury (early and
common finding)
– Persistent deep ache or burning pain
– Paresthesias (onset within approximately 30 minutes to two
hours of ACS; suggests ischemic nerve dysfunction)

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Examination findings of ACS include:
– Pain with passive stretch of muscles in the affected
compartment (early finding)
– Tense compartment with a firm "wood-like" feeling
– Pallor from vascular insufficiency (uncommon)
– Diminished sensation
– Muscle weakness (onset within approximately 2 to 4h of ACS)
– Paralysis (late finding)

• The Classic 5Ps are not that reliable; pain out of proportion is more reliable (but
polytrauma pt, children, post nerve block, obtunded,..)

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 Work up

• Labs
– High serum creatine Kinase (CK)
– Myoglobinuria– 4 hours of onset

• Compartement pressure measurement:

– Not required to diagnose ACS but preferable in unconscious,
polytrauma pt, unconclusive P/E & Hx
– Inject a small saline amount 5cm from fracture site &
record tissue resistance pressures
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 ICP interpretations

– Normal CP: 0 to 8 mmHg

– Capillary blood flow compromise: 25-30mmHg
– Pain is set at 20-30mmHg
– Ischemia occurs when tissue pressures approach diastolic
pressure
– Higher pressures for ACS in HTN patients
– Lower pressures in hypotensive and peripheral vascular diseased

– DBP-ICP<30mmHg confirms ACS (used at some centres as cut off

for fasciotomy)

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 Management

o Remove cast/bandage, stop extravasation IVF

o Positioning of the limb at the level of the
heart(maintains arterial blood inflow and do not elevate the affected
limb, it decreases arterial pressure, gravity
o IV hydration to avoid hypotension
o Oxygen supplement
o Analgesics

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 Fasciotomy
• Indications :
– Positive clinic and
– ICP : 30-45 mm Hg (or DBP/ICP difference <30mmHg)
• The principles of fasciotomy include
– Adequate and extensile incision
– Complete release of all involved compartment
– Preservation of vital structure
– Thorough debridement
– Skin coverage at a later date (7-10 days)

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 Fasciotomy techniques
I. Arm-2cp

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 II. Forearm-4cp

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 III. Hand-4cp

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 IV. Thigh-3cp

A single lateral incision is usually

adequate to decompress the thigh
as the medial compartment is only
rarely involved.

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 V. Leg-4cp
o Anterior compartment : TA, EDL,
EHL and peroneus tertius
o Lateral compartment : peroneus
longus and brevis.
o Posterior superficial
compartment : gastrocnemius and
soleus
o Posterior deep compartment :
tibialis posterior,flexor hallucis
longus and flexor digitorum
longus.

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 Foot-9Cp

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Medial Incision Dorsal Dual Incision

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After fasciotomy:

– Fixation of fractures: IMN, External fixation

– Sterile dressing, splinting in functional position
– Wound second look or debridement is necessary
within 48-72 hours

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 Complications of fasciotomy

– Altered sensation within the margins of the wound (77%)

– Dry, scaly skin (40%)
– Pruritus (33%)
– Discolored wounds (30%)
– Swollen limbs (25%)
– Tethered scars (26%)
– Recurrent ulceration (13%)
– Muscle herniation (13%)
– Pain related to the wound (10%)
– Tethered tendons (7%)

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 Prognosis of ACS
• If delayed action or missed ACS, permanent disabilities
ensue:
– Mortality to patients requiring fasciotomy: 15% of cases
– Contracture
– Amputation
– Sensory deficits
– Paralysis
– Infection
– Fracture nonunion
– Renal failure --- from rhabdomyolysis and resultant
myoglobinuria

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 References
• Review of surgery
• Schwartz principles of surgery, 10th edition
• McQueen MM, Gaston P, Court-Brown CM.
Acute compartment syndrome. Who is at risk?
J Bone Joint Surg Br 2000; 82:200.
• Amercan academy of orthopedic surgeons,
ACS guidelines 30
• Up to date, online resources 2019

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