COMPARTMENT SYNDROMECOMPARTMENT SYNDROME
Dr.Chowdhury Iqbal Mahmud
MBBS,FRCS(UK),MCh(MS, Ortho,Uk)
PG Cert. in Plaster Technology (UK)
Fellow in Orthopaedics ( Singapore)
Registrar (Orthopaedics)
BIRDEM & IMC
1
ACUTE COMPARTMENT ACUTE COMPARTMENT SYNDROMESYNDROME
Compartment Syndrome is a true orthopaedic emergency andits outcome depends on the timeliness of the Intervention.
2
ACUTE COMPARTMENT ACUTE COMPARTMENT SYNDROMESYNDROME
Why it is important to treat urgently
Volkmann’s Ischaemic contracture
3
ACUTE COMPARTMENT ACUTE COMPARTMENT SYNDROMESYNDROME
History:
Volkmann 1881 (described) Petersen 1888 (treatment) Hildenbrand 1906 (ischaemic contracture) Rowlands 1910 (reperfusion) Murphy 1914 (fasciotomy) WW2 (arterial spasm) Kelly & Whitesides (1967) 4 Compartment Leg McQueen & Court-Brown (1990’s)
4
INTRODUCTIONINTRODUCTION
What is CS?
Definition:
Compartment syndrome is a condition characterised by raised pressure within a closed space with a potential to cause irreversible damage to the contents of the closed compartment.
Acute compartment syndrome is a potentially devastating condition in which the pressure within an osseofascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia, and death.
5
INTRODUCTIONINTRODUCTION
Where does it occur?Compartment syndrome (CS) is a condition in which the perfusion pressure
falls below the tissue pressure in a closed anatomic space ( compartment), with
subsequent compromise of tissue circulation and function.
Each muscle or muscle group is enclosed in a compartment bound by relatively
rigid walls of bone and fascia. The compartments of the lower leg and the volar
forearm are particularly prone to developing elevated compartment pressures.
6
INTRODUCTIONINTRODUCTION
Where does it occur?
Lower Extremity Gluteal Thigh Lower Leg Foot
Upper Extremity Deltoid Arm Forearm Hand
7
ETIOLOGYETIOLOGY
Why does it occur?Any condition that reduces the volume of a compartment or increasesthe content of a compartment can lead to an acute compartment syndrome.
Reduce the Volume Cast or Splint Circumferential constricting dressing Closure of fascia Military antishock trousers (MAST) 3rd degree Burns (circumferential) Lithotomy position Malfunctioning sequential compression devices (SCDs) Tight ski boots
8
ETIOLOGYETIOLOGY
Gunshot wound to thigh Drug/alcohol abuse and coma Compartment fluid injection Crush injuries Gastronomies or peroneus muscle
tear Androgen abuse/muscle
hypertrophy Knee arthroscopy Ruptured Baker cyst
Increase the Content
Fractures, direct tissue trauma Hemorrhage: vascular injury,
coagulopathy, anti-coagulation Increased capillary permeability
after burns Infusion or injection (infiltrated
line) Extravasation of arthroscopic fluid Reperfusion after period of
ischemia Basement membrane damage
transudate after arterial inflow is reestablished
Why does it occur?
As many as 45% of all cases of CS are caused by tibial fractures
9
ETIOLOGYETIOLOGY
Both close and open fracture can cause compartment syndrome
10
ETIOLOGYETIOLOGY
Don’t ForgetCS can occur withopen fracture
198 open fracture
9.1% CS
Blic et al JBJS 1986
Why does it occur?
11
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Compartment Pressures Rise
Venous obstruction occurs, causing further pressure escalation
Low intramuscular arteriolar pressure is exceeded
MUSCLE AND NERVE ISCHEMIA
12
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Muscle – reversible damage after 4 hours; irreversible after 8 hours
Nerve damage irreversible after 8 hours Tissue perfusion is directly related to the perfusion
gradient in the compartment. Episodes of HYPOTENSION will therefore increase the
extent of irreversible muscle damage In tissue damaged by injury, resistance to ischemia is
decreased. A pressure of 20mm Hg below diastolic shown to cause ischemia
Decreased tissue perfusion
tissue death
13
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Ischaemic fibrotic contracture
Areas of muscle infarction
•Rabdomyolysis•Hypovolumia•Hyperkalamia•Increase uric acid•Metabolic acidosis
Hypovolumia + myoglobulinaemia
Acute renal failure
Hyperkalamia Cardiac arrest
14
Tissueswelling
IschaemiaIschaemia
Muscle
Pain & spasm
Nerve
Paraesthesia
Compartment
pressure
Arteriolar
stasis
Venous
stasis
15
MANAGEMENTMANAGEMENT
Pre-hospital/at site management
Oxygen; high flow
Do NOT ice; ice increase vasoconstriction
Do NOT elevate; keep in position where found or position of comfort
Splint for comfort and protection only when necessary ( i. e. long transport)
Transport to appropriate medical facility (trauma?);heads up to receiving medical facility
16
MANAGEMENTMANAGEMENT
The initial evaluation of a patient with an injury should always follow the principles and guidelines of the Advanced Trauma Life Support System.
Primary Survey (ABCDE) & Resuscitation Adjuncts to Primary Survey & Resuscitation Consider need for Patient Transfer Secondary Survey (with AMPLE History) Continued Post-Resuscitation Monitoring & re-evaluation Transfer to Definitive Care
17
MANAGEMENTMANAGEMENT
NEVER FORGET TO DO
PRIMARY SURVEY
A - Airway & Cervical Spine Control
B - Breathing & Oxygenation
C - Circulation & Haemorrhage Control
D - Dysfunction & Disability of the CNS
E - Exposure & Environmental Control
18
MANAGEMENTMANAGEMENT
History
Type of trauma Mechanism of trauma Time since trauma Risk factors Co- morbidities
Physical Examination
19
MANAGEMENTMANAGEMENT
Risk FactorsSpecific injuries
Tibia fractures Distal humerus fractures Forearm fractures Arterial Injury Venous Injury Crush injury Entrapment
Systemic Shock/ Hypotension Overdose/
Unconsciousness
20
MANAGEMENTMANAGEMENT
Diagnosis
Compartment syndrome is a clinical diagnosis Frequently confusing Many classic signs may be absent High index of suspicion is critical
◦ Recognize the risk factors
◦ Inform and educate patient, family, caregivers
21
MANAGEMENTMANAGEMENT
DiagnosisClassic FeaturesThe 5 P’s PainParesthesias Paralysis Pallor Pulselessness
Never have more than two “P”sPulse may be palpable in CS
These are not always reliable clinical feature
22
MANAGEMENTMANAGEMENT
Diagnosis
Pain out of proportion to injury. The pain is also deep and aching in nature and is worsened by passive stretching of the involved muscles. The patient may describe a tense feeling in the extremity. Pain, however, should not be a sine qua non of CS. Paresthesia, or numbness, is an unreliable early symptom.
First complaint of a conscious patient High analgesia requirement Not improved with repositioning or immobilization Transient, minimal relief after release of dressings
23
MANAGEMENTMANAGEMENT
DiagnosisPhysical Exam
Firm, tense, tender and swollen compartments.
Pain on passive stretch most sensitive sign before onset of ischemic nerve and muscle dysfunction.
24
MANAGEMENTMANAGEMENT
Late Diagnostic sign
Hypesthesia or paresthesia Motor deficits Pulselessness should not develop in the absence of arterial
injury Capillary refill is usually unaffected Loss of distal pulses and capillary refill rarely occur in
compartment syndrome without arterial injury or pressures approaching the patient’s SYSTOLIC BP
25
MANAGEMENTMANAGEMENT
DiagnosisSequence of findings: Pain out of proportion, not
relieved by repositioning or removal of dressings
Firm compartments Pain on passive toe motion Mild EHL weakness Florid EDL weakness 1st web space
hypoesthesia
26
MANAGEMENTMANAGEMENT
Diagnosis
Key point: Pain will diminish after pressure-induced ischemia
affects the conductivity of the nerves in the compartment.
A painless state will ensue.
27
MANAGEMENTMANAGEMENT
DiagnosisConfounding Factors Pain and swelling are expected sequelae of trauma and
surgery Neurologic deficits may result from initial injury and not
compartment syndrome Patient may not be able to cooperate with exam Regional anesthesia may mask pain
If compartment syndrome is possible, this is a relative
contraindication to: Long-acting nerve blocks Continuous epidural anesthesia
28
MANAGEMENTMANAGEMENT
29
MANAGEMENTMANAGEMENT
Diagnosis
TISSUE PRESSURE MEASUREMENT Compartment syndrome is a clinical diagnosis Don’t need to measure to prove it May need to measure to exclude it Reference point for pain level
INDICATIONS Polytrauma Patients History and symptoms unobtainable Low diastolic pressures Recommend regular checks or continuous monitoring Chemically overdosed or head injury Inconclusive clinical diagnosis Coexisting nerve injury and swelling
Portable Stryker pressure monitor
Manometer
30
MANAGEMENTMANAGEMENT
Diagnosis
Tissue pressure measurement
What tissue pressure is abnormal?
Absolute 45 mm Hg if diastolic 70mm Hg or higher
Relative < 20-30 mm Hg below diastolic pressure (Whitesides et al., Journal of American Academy of Orthopaedic
Surgeons, 1996 )
[Normal compartment pressures < 10 mm HG]
Diastolic pressure - compartment pressure less than 30 mm Hg
31
MANAGEMENTMANAGEMENT
Differential diagnosis Cellulitis Deep Venous Thrombosis and Thrombophlebitis Gas Gangrene Necrotizing Fasciitis Peripheral Vascular Injuries Rhabdomyolysis
32
MANAGEMENT MANAGEMENT (INVESTIGATION)(INVESTIGATION)
Lab Studies Hematology/chemistry laboratory studies – Serum myoglobin and CK
measurements should be obtained to determine the degree of muscle necrosis. ◦ Serial CK levels may show increases indicative of a developing CS. ◦ High CK levels should alert the physician to possible rhabdomyolysis.
Renal function/chemistry panel ◦ Blood urea nitrogen (BUN) and creatinine are measured. ◦ Potassium level is needed in cases of rhabdomyolysis. ◦ Severe hyperkalemia may result in a wide complex and possibly fatal
arrhythmia. Complete blood cell count (CBC) and coagulation studies
◦ Anemia worsens muscle ischemia. ◦ Look for disseminated intravascular coagulation (DIC), which is rare.
Preoperative laboratory studies Urinalysis to determine myoglobin and CK (if available)
◦ A urine dip may show blood but no red blood cells (RBCs), which indicates the presence of myoglobin.
33
MANAGEMENT MANAGEMENT (INVESTIGATION)(INVESTIGATION)
Imaging Studies Plain radiographs of the affected extremity are used to
determine fracture pattern, soft-tissue injury, and radiographic clues that may indicate occult fractures.
MRIs may show increased signal intensity in an entire compartment on T2-weighted, spin-echo sequences.
Computed tomography (CT) scanning is especially useful if pelvic or thigh CS is in the differential diagnosis.
Lower extremity venous Doppler or arterial ultrasonography (US) is performed as needed to address possible DVT or arterial occlusion.
US alone is not useful in making the diagnosis of CS.
34
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT)
Medical therapy Place the affected limb(s) at the level of the heart. Elevation
is contraindicated because it decreases arterial blood flow and narrows the arteriovenous pressure gradient and thus worsens the ischemia.
Remove cast, bandages and any dressing. Reduce compartment pressure by releasing one side of a plaster cast, which can reduce the pressure by 30%; bivalving can produce an additional 35% reduction and cutting bandages decrease the compartmental pressure by 10-20%.
Correct hypo perfusion with crystalloid solution and blood products.
35
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT)
Medical therapy
Mannitol may reduce compartment pressures and lessen reperfusion injury.
Vasodilator drugs or sympathetic blocking drugs appear to be ineffective in the treatment of CS, probably because, in this condition, maximal local vasodilatation is already present.
Administer antivenin in cases of snake bite; this may reverse a developing CS.
36
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT)
Surgical Therapy
The definitive surgical therapyfor compartment syndrome isemergent fasciotomy(compartment release) with subsequent orthopedicreduction or fracturestabilization and vascularrepair, if needed.The goal of decompression isrestoration of muscle perfusionwithin 6 hours.
37
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT)
Surgical TherapyFasciotomy in different parts
38
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT) Surgical treatment( Fasciotomy )in Lower Leg:Surgical treatment( Fasciotomy )in Lower Leg:
Anterior compartment ◦ Dorsiflexion muscles of the ankle and foot
Tibialis anterior Extensor digitorum longus Extensor hallucis longus Peroneus tertius
◦ Anterior tibial artery – Commonly injured in lateral tibial plateau fractures
◦ Deep peroneal nerve – Provides sensation to the first dorsal web space
Lateral compartment ◦ Peroneus brevis and peroneus longus –
Plantar flexor and evertor muscles of the foot
◦ Superficial peroneal nerve – Provides sensation to the dorsum of the foot
Deep posterior compartment ◦ Plantar flexor and phalangeal flexor
muscles Tibialis posterior Flexor digitorum longus (FDL) Flexor hallucis longus
◦ Posterior tibial and peroneal arteries ◦ Posterior tibial nerve – Provides
sensation to the sole of the foot
Superficial posterior compartment ◦ Plantar flexor muscles of the foot
Gastrocnemius Plantaris Soleus
◦ Sural nerve – Provides sensation to the lateral aspect of the foot and distal calf
Relevant anatomy of lower leg compartment39
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT)
Surgical Treatment
( Fasciotomy ) in Lower Leg:
Single- and double-incision techniques have been described. The double-incision technique is safer and more effective and should be used in general.
40
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT)
Surgical Treatment( Fasciotomy )in Lower Leg:
41
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT)
Surgical Treatment( Fasciotomy )in Lower Leg:
42
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT) Surgical treatment( Fasciotomy )in Lower Leg:Surgical treatment( Fasciotomy )in Lower Leg:
The anterior and lateral compartments are approached through 1 incision.
Make an approximately 15-cm incision over the anterior intermuscular septum, centered halfway between the fibular shaft and the crest of the tibia( 2 cm lat. To the ant. Tibial border). The incision must be large enough to provide adequate visualization. In an elective decompression, a 4- to 5-cm incision may be adequate.
Use subcutaneous dissection for wide exposure of the fascial compartments.
Make a transverse incision to expose the lateral intermuscular septum and to identify the superficial peroneal nerve just deep to the septum.
Make a small nick in the anterior intermuscular septum midway between the septum and tibial crest.
Using Metzenbaum scissors or a fasciotome, release the anterior compartment proximally (aim for the patella) and distally (aim for the center of the ankle) in line with the tibialis anterior.
Then, perform a longitudinal fasciotomy of the lateral compartment in line with the fibular shaft. Direct the scissors toward the lateral malleolus to stay posterior to the superficial peroneal nerve.
43
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT) Surgical treatment( Fasciotomy )in Lower Leg:Surgical treatment( Fasciotomy )in Lower Leg:
Make a second longitudinal incision 1-2 cm posterior to the posterior medial margin of the tibia.
Use wide subcutaneous dissection to allow identification of the fascial planes.
Retract the saphenous vein and nerve anteriorly. Make a transverse incision to identify the septum between the deep and superficial posterior compartments. Release the fascia over the superficial posterior compartment. Release the fascia over the gastrocsoleus complex along the length of the compartment.
Make another fascial incision over the FDL muscle and release the entire deep posterior compartment.
As the surgical dissection is carried proximally, note the origin of the soleus from the proximal third of the tibia. Detach the soleal bridge, and retract to expose the FDL and tibialis posterior.
After release of the posterior compartment, identify the tibialis posterior muscle compartment. If increased tension is evident in this compartment, release it over the extent of the muscle body.
Pack the wound open and apply a posterior plaster splint with the ankle held at 90°. Return the patient to the operating room for debridement in 1-3 days if necessary or for skin closure.
44
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT)
Fracture Fixation
45
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT) Surgical treatment( Fasciotomy )in Lower Leg:Surgical treatment( Fasciotomy )in Lower Leg:
Post-operative wound closure
46
MANAGEMENT (TREATMENT)MANAGEMENT (TREATMENT) Surgical treatment( Fasciotomy )in Lower Leg:Surgical treatment( Fasciotomy )in Lower Leg:
Contraindication to Fasciotomy If CS is diagnosed late, fasciotomy is of little
benefit. In fact, fasciotomy is probably contraindicated after the third or fourth day following the onset of CS, and when performed late, severe infection usually develops in the necrotic muscle.
47
OUTCOMEOUTCOME
Depends upon the timeliness of diagnosis and treatment
Dependent upon etiology and age of patient
If recognized and treated before my necrosis, >90% recover function
May have some loss of muscle power due to the fasciotomy
48
Chronic exertional compartment Chronic exertional compartment syndromesyndrome
Chronic exertional compartment syndrome is an exercise-induced neuromuscular condition that causes pain, swelling and sometimes even disability in affected muscles of the legs or arms. The condition can occur in both beginning and seasoned athletes in sports that involve repetitive movements, such as running, fast walking, biking and swimming. Chronic exertional compartment syndrome is sometimes called chronic compartment syndrome or exercise-induced compartment syndrome.
In chronic exertional compartment syndrome, the repetitive activity causes tissue in the affected muscle area, or compartment, to swell. That, in turn, increases pressure within the compartment, leading to a decreased blood supply to the muscles. This can cause injury to the muscle and nerves, sometimes resulting in permanent damage.
49
SUMMARYSUMMARY
Acute compartment syndrome is a potentially devastating condition in which the pressure within an osseofascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle Ischemia, and death.
A variety of injuries and medical conditions may initiate acute compartment syndrome, including fractures, contusions, bleeding disorders, burns, trauma, post-ischemic swelling, and gunshot wounds.
Diagnosis is primarily clinical, supplemented by compartment pressure measurements.
Certain anesthetic techniques, such as nerve blocks and other forms of regional and epidural anesthesia, reportedly contribute to a delay in diagnosis.
50
SUMMARYSUMMARY
Basic science data suggest that the ischemic threshold of normal muscle is reached when pressure within the compartment is elevated to 20 mm Hg below the diastolic pressure or 30 mm Hg below the mean arterial blood pressure.
On diagnosis of impending or true compartment syndrome, immediate measures must be taken.
Complete fasciotomy of all compartments involved is required to reliably normalize compartment pressures and restore perfusion to the affected tissues.
Recognizing compartment syndromes requires having and maintaining a high index of suspicion, performing serial examinations in patients at risk, and carefully documenting changes over time.
51
MY WEB SITE WWW.ORTHODOC.AAOS.ORG/MAHMUDFRCS
52