Compartment Syndrome

Compartment syndrome
R1.Kornrawee/ Staff.Wich
● ACS = elevation of intracompartmental pressure (ICP) to a level and for a
duration that without decompression will cause tissue ischemia and necrosis
● Exertional compartment syndrome = the elevation of ICP during exercise,
causing ischemia, pain, and rarely neurologic symptoms and signs.
● The crush syndrome = the systemic result of muscle necrosis commonly
caused by prolonged external compression of an extremity.
Volkmann's ischemic
contracture
● End stage of neglected
ACS
● Irreversible muscle
necrosis
● Ischemic contractures.
https://www.eu.elsevierhealth.com/media/blfa_files/Green_Chapter_51_main.pdf
Epidemiology
● 3.1/100,000 population per year
● Male > Female (10:1)
● Mean age at 32 yrs
○ Male: 30 yrs
○ Female: 44 yrs
● Younger > Older
○ Muscle bulk
○ Hypertension in elderly
● Fractures 69%
● Children
○ Tibial diaphyseal
○ Distal radius
○ Forearm
● Adult
○ Tibial diaphyseal
Tibial diaphyseal fx = Low-energy injury 59%

Open fx:
● Lower Gustilo types = More risk
● Lack of boundaries disruption
Distal radius and
forearm diaphyseal
● High-energy injury
Pathogenesis
● Critical closing pressure theory
● Arteriovenous (AV) gradient theory
● Microvascular occlusion theory
Critical closing pressure theory
● Closing pressure in small vessels when transmural pressure (TM) drops
● Transmural pressure balanced constricting force [active and elasticity vessel]
TM = RC/r
● Maintaining arteriolar closure = strong stimulus for vasodilatation

● Flow resumes 30-60 sec. of maintained tissue pressure
Arteriovenous (AV) gradient theory
● Tissue pressure increase -> Low AV gradient
● Local blood flow primarily determined by AV gradient
LBF = (Pa - Pv)/ R
● Venous and capillary flow ceased

● Arterioles still capable to carrying flow
Microvascular occlusion theory
● Capillaries are collapsible at the similar tissue pressure
● Tissue ischemia
○ permeability increase -> edema and lymphatic obstruction
○ Reactive hyperemia and vasodilatation
Tissue pressure Perfused capillaries per unit area

Muscle
● Critical tissue pressure threshold
○ 10 - 20 mmHg below DBP
○ 25 - 30 mmHg below MAP
○ > 30 mmHg in previous traumatized or ischemic muscle
● Type I fibers: oxidative metabolism of TG >> more vulnerable ACS
● Type II fibers: primarily anaerobic
Nerve Bone
● Loss neuromuscular function ● Nonunion
● Varying pressure threshold and ● Volkmann’s disease
duration ○ Musculodiaphyseal vessel
● Cause of injury collapse -> pseudoarthrosis
○ Ischemia ○ Reduce extraosseous blood
○ Ischemia + compression supply -> poor long bone healing
○ toxic effects
○ acidosis
Reperfusion injury
● After re-establish blood flow to ischemic tissue -> inflammatory response
● Breakdown products of muscle
○ Inflammatory mediators [histamine, interleukin, oxygen free radicals, thromboxane]
○ Procoagulants -> microvascular thrombosis, coagulopathy
Inflammatory Vascular Increased

Worsening ICP
mediators endothelium permeability
Diagnosis
● Clinical diagnosis (High index of suspicious)
● Compartment pressure monitoring
Clinical diagnosis
● Pain out of proportion
● Pain with passive stretch of muscles
● Paresthesia: nerve ischemia/injury
Late sign
● Paralysis: poor prognosis
● [R/O pain, muscle injury, nerve injury]
● Palpable swelling in compartment
Peripheral pulse and capillary refill always intact

Compartment pressure monitoring
● Noninvasive technique
○ Near-infrared spectroscopy
● Invasive technique
○ Needle manometer
○ Wick catheter
○ Transducer-tip intracompartment catheter (STIC)
○ Slit catheter
Near-infrared spectroscopy
● Measure tissue oxygen saturation
Good accuracy and correlation

Continuous monitoring feasible
Noninvasive technique
Increased costs
Not yet clearly validated for ACS
Measurement dependent on soft
tissue depth
https://www.researchgate.net/figure/Portable-near-infrared-spectroscopy-
NIRS-monitor-in-use-The-probe-is-placed-over-the_fig1_224925131
Needle manometer (Whiteside technique)
● Simple technique
● Low cost
● Accuracy limited with false

positives/negatives
● Invasive indirect measure
● Continuous measurement
unfeasible
● Needle tip may block
● Fluid infusion can cause clinical
picture to deteriorate
Wick catheter
● Modification of needle technique -> Larger surface area, prevent needle obstruction
Good accuracy with high surface area

Blockage of catheter uncommon
Invasive indirect measure

Blockage at air/fluid junction possible
Wick material retention possible
Transducer must be at catheter level
Slit catheter
Good accuracy with high surface area

Invasive indirect measure

Catheter may block
Air bubble can lead to false low reading
Transducer must be at catheter level
Transducer-tip intracompartment catheter (STIC)
Good accuracy
Continuous monitoring
feasible
Transducer level not
important
Increased costs
Resterilization necessary
Placement
● Catheter tip: ≤ 5 cm of level
of fx site
● Inaccurately high due to
fracture hematoma
Threshold pressure for decompression
● Normal resting ICP in adult = 10 mmHg
● Critical ICP pressure = 30 mmHg; close to capillary blood pressure
● Differential pressure (ΔP)

○ DBP - Tissue pressure ≤ 30 mmHg
○ Critical ΔP increased in traumatized/
ischemic muscle
PPV 92.8% NPV 98.7%

Timing
● Fasciotomy should not be performed based on pressure
○ False-positive 35%
ICP is rising + ΔP is dropping ≤ 30 mmHg for 2 hrs

Treatment
The most effective treatment for ACS is fasciotomy.
Impending ACS
● Release of external limiting envelopes; dressings or plaster casts
● Splitting and spreading a cast
● The limb should not be elevated above the height of the heart
● Hypotension should be corrected
● Oxygen therapy
Fasciotomy
Full and adequate decompression
● Visualize all contained muscles

● Assess their viability
● Debride necrotic muscles to avoid
infection.
Surgical and applied anatomy
● Thigh
● Leg
● Foot
● Arm
● Forearm
● Hand
Thigh
● A single lateral skin incision
● Measure medial compartment pressure after release ant. and post.compartment
○ If elevated pressure, separated medial incision should perform
Leg
● Single-incision
○ Difficult to visualize full extent of
deep posterior compartment
● Double-incision
○ Faster and safer
○ Lateral: 2 cm. ant to fibula [supf.
peroneal nerve = 10 cm. above lat.
malleolus]
○ Medial: 1-2 cm post. to tibia
[saphenous vein and nerve, ]
Foot
● Dorsal incisions at 2nd and 4th metacarpals
○ interosseous and central compartment
● Deep surfaces of 1st and 5th metatarsal
○ medial and lateral compartments
Hindfoot injury [Calcaneus] = Medial incision ->

Calcaneus compartment
Arm
Anterior and posterior incisions
Forearm
● Volar incision [usually sufficient]
○ Proximal forearm -> palm (carpal tunnel
decompression)
○ Fascial incision -> deep flexors
● Dorsal incision
Hand
Volar interosseous compartments
● Not functionally separate from the dorsal interosseous compartments
● Tissue barrier cannot withstand pressures of more than 15 mmHg
Thenar
● thenar fascia Hypothenar
● thenar septum ● hypothenar fascia
● the 1st metacarpal and septum
● the 5th metacarpal
Dorsal interosseous
● Between metacarpals
● Interosseous fascia anteriorly
and posteriorly
2 dorsal incisions [often sufficient]
● access to the interosseous
compartments
● If clinical suspicion or raised ICP on
measurement = incision over thenar and
hypothenar eminences
Management of fasciotomy wound
● Left open and dressed
● 48 hours after fasciotomy, => “second-look"
○ viability of all muscle groups
○ Skin closure or cover when all muscle
groups are viable.
● Delayed primary closure
○ Vessel loop shoelace technique
○ Vacuum-assisted closure system
Fasciotomy should be performed prior to fracture stabilization
Stabilization >> easy access to the soft tissues and protects the soft
tissues, allowing them to heal.
Cast is contraindicated
Avoid
● Excessive traction: deep posterior compartment

raised by approximately 6%/kg of weight applied
● Poor positioning of thigh bar (external calf
compression)
● High elevation of leg (90-90 position)
Delay diagnosis & Complications
● Delay to fasciotomy > 6 hours
○ infection
○ muscle necrosis and contractures
○ permanent neurologic injury
○ chronic pain
○ nonunion
● Partial muscle necrosis and compartment pressures above the threshold for
decompression
○ Fasciotomy should be performed to salvage remaining viable muscle.
● No likelihood of any surviving muscle and compartment pressures are low
○ Fasciotomy should be withheld.
TAKE HOME MESSAGE
● Urgent fasciotomy primarily using ICP monitoring and the differential
pressure (ΔP)
○ < 30 mm Hg for more than 2 hours
● Full length of affected compartment
● Relook at 48 hours after fasciotomy -> further debridement
● Delay diagnosis and treatment -> poor complications

Compartment Syndrome

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Compartment syndrome

Tibial diaphyseal fx = Low-energy injury 59%

● Maintaining arteriolar closure = strong stimulus for vasodilatation

LBF = (Pa - Pv)/ R

● Venous and capillary flow ceased

Tissue pressure Perfused capillaries per unit area

Inflammatory Vascular Increased

Peripheral pulse and capillary refill always intact

Good accuracy and correlation

● Accuracy limited with false

Good accuracy with high surface area

Invasive indirect measure

Good accuracy with high surface area

Invasive indirect measure

● Differential pressure (ΔP)

PPV 92.8% NPV 98.7%

ICP is rising + ΔP is dropping ≤ 30 mmHg for 2 hrs

The most effective treatment for ACS is fasciotomy.

Full and adequate decompression

● Visualize all contained muscles

Hindfoot injury [Calcaneus] = Medial incision ->

● Excessive traction: deep posterior compartment

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