COMPARTMENT COMPARTMENT SYNDROMESYNDROME

JAYANT SHARMAJAYANT SHARMAM.S.,D.N.B.,M.N.A.M.S.M.S.,D.N.B.,M.N.A.M.S.

Compartment SyndromeCompartment SyndromeDEFINITIONDEFINITION Elevated tissue pressure within a Elevated tissue pressure within a

closed fascial spaceclosed fascial space Reduces tissue perfusion - ischemiaReduces tissue perfusion - ischemia Results in cell death - necrosisResults in cell death - necrosis True Orthopaedic EmergencyTrue Orthopaedic Emergency

HistoryHistory Volkmann 1881Volkmann 1881 Richard von VolkmannRichard von Volkmann

published an article in which published an article in which he attempted to describe the he attempted to describe the condition of irreversible condition of irreversible contractures of the flexor contractures of the flexor muscles of the hand to muscles of the hand to ischemic processes occurring ischemic processes occurring in the forearm in the forearm

Application of restrictive Application of restrictive dressing to an injured limbdressing to an injured limb

Hildebrand 1906Hildebrand 1906 First used the term Volkmann ischemic First used the term Volkmann ischemic

contracture to describe the final result contracture to describe the final result of any untreated compartment of any untreated compartment syndrome, and was the first to syndrome, and was the first to suggest that elevated tissue pressure suggest that elevated tissue pressure may be related to ischemic may be related to ischemic contracture. contracture.

Thomas 1909Thomas 1909 Reviewed the 112 published cases of Reviewed the 112 published cases of

Volkmann ischemic contracture and Volkmann ischemic contracture and found fractures to be the predominant found fractures to be the predominant cause.cause.

Also, noted that tight bandages, an Also, noted that tight bandages, an arterial embolus, or arterial arterial embolus, or arterial insufficiency could also lead to the insufficiency could also lead to the problem problem

Murphy 1914Murphy 1914 First to suggest that Fasciotomy might First to suggest that Fasciotomy might

prevent the contracture. prevent the contracture. Also, suggested that tissue pressure Also, suggested that tissue pressure

and Fasciotomy were related to the and Fasciotomy were related to the development of contracture development of contracture

Ellis 1958Ellis 1958 Reported a 2% incidence of Reported a 2% incidence of

compartment syndrome with tibia compartment syndrome with tibia fractures, and increased attention was fractures, and increased attention was paid to contractures involving the paid to contractures involving the lower extremitieslower extremities

Seddon, Kelly, and Whitesides 1967Seddon, Kelly, and Whitesides 1967 Demonstrated the existence of 4 Demonstrated the existence of 4

compartments in the leg and to the need to compartments in the leg and to the need to decompress more than just the anterior decompress more than just the anterior compartment.compartment.

Since then, compartment syndrome has Since then, compartment syndrome has been shown to affect many areas of the been shown to affect many areas of the body, including the hand, foot, thigh, and body, including the hand, foot, thigh, and buttocks. buttocks.

Compartment SyndromeCompartment SyndromeEtiologyEtiology

Compartment SizeCompartment Size tight dressing;tight dressing; Bandage/CastBandage/Cast localised external pressure;localised external pressure; lying on limblying on limb Closure of fascial defectsClosure of fascial defects

Compartment ContentCompartment Content Bleeding; Fractures, vascular inj, bleeding Bleeding; Fractures, vascular inj, bleeding

disordersdisorders Capillary Permeability;Capillary Permeability;

Ischemia / Trauma / Burns / Exercise / Snake Bite / Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection / IVFDrug Injection / IVF

Fracture

The most common causeThe most common cause incidence of accompanying incidence of accompanying

compartment syndrome of compartment syndrome of 9.1%9.1%

The incidence is directly The incidence is directly proportional to the degree of proportional to the degree of injury to soft tissue and boneinjury to soft tissue and bone

occurred most often in occurred most often in association with a association with a comminuted, grade-III open comminuted, grade-III open injury to a pedestrianinjury to a pedestrian

Blick et al JBJS 1986Blick et al JBJS 1986

Blunt Trauma 2nd most common cause2nd most common causeAbout 23% of CSAbout 23% of CS25% due to direct blow25% due to direct blow

IncidenceIncidence

164 pts with CS, 149 male, 15 female164 pts with CS, 149 male, 15 female Most pts were usually under 35 Most pts were usually under 35 69% with associated fx, about half 69% with associated fx, about half

were tibial shaftwere tibial shaft 23% soft tissue injury without fx23% soft tissue injury without fx Ranges of 2-12% have been Ranges of 2-12% have been

publishedpublishedMcQueen et al; JBJS Br 2000McQueen et al; JBJS Br 2000

IncidenceIncidence

Type of Type of FxFx

% of % of ACSACS

IncidencIncidence all e al l agesages

Incidence Incidence <35<35

Tibial Tibial diaphysidiaphysiss

36%36% 4.3%4.3% 5.9%(3 fold)5.9%(3 fold)

Distal Distal radiusradius

9.8%9.8% 0.25%0.25% 1.4%(30 1.4%(30 fold)fold)

Forearm Forearm diaphysidiaphysiss

7.9%7.9% 3.1%3.1% 3.2%3.2%

Patient Posit ioningPatient Posit ioning

Leaving the calf free when the leg is placed Leaving the calf free when the leg is placed in the hemilithotomy position.in the hemilithotomy position.

Instead of using a standard well-leg holderInstead of using a standard well-leg holder Increases the difference between the Increases the difference between the

diastolic blood pressure and the diastolic blood pressure and the intramuscular pressure.intramuscular pressure.

May decrease the risk of compartment May decrease the risk of compartment syndrome. syndrome.

-Meyer, Mubarak JBJS 2002

Patient posit ioningPatient posit ioning

Meyer, Mubarak JBJS 2002

PathophysiologyPathophysiology Normal tissue pressureNormal tissue pressure

– 0-4 mm Hg 0-4 mm Hg – 8-10 with exertion8-10 with exertion

Absolute pressure theoryAbsolute pressure theory– 30 mm Hg - Mubarak30 mm Hg - Mubarak– 45 mm Hg - Matsen45 mm Hg - Matsen

Pressure gradient theoryPressure gradient theory– < 20 mm Hg of diastolic pressure – < 20 mm Hg of diastolic pressure – Whitesides & McQueen, et alWhitesides & McQueen, et al

Tissue SurvivalTissue Survival

MuscleMuscle– 3-4 hours - reversible changes3-4 hours - reversible changes– 6 hours - variable damage6 hours - variable damage– 8 hours - irreversible changes8 hours - irreversible changes

NerveNerve – 2 hours - looses nerve conduction2 hours - looses nerve conduction– 4 hours - neuropraxia4 hours - neuropraxia– 8 hours - irreversible changes8 hours - irreversible changes

PathophysiologyPathophysiology

Pressure increases exceeding low Pressure increases exceeding low intramuscular arterioles decreasing intramuscular arterioles decreasing capillary blood flow -Cap pressure 20-capillary blood flow -Cap pressure 20-30mmHg30mmHg

If prolonged pressure causes necrosis If prolonged pressure causes necrosis of the tissuesof the tissues

Pressure >30mmHgPressure >30mmHg results in nerve results in nerve conduction velocity blockage after 6-8 conduction velocity blockage after 6-8 hrs and irreversibility after 8 hrs hrs and irreversibility after 8 hrs (normal pressure 4mmHg)(normal pressure 4mmHg)

--Hargens --Hargens

PathophysiologyPathophysiology

Necrosis causes cell death and Necrosis causes cell death and inflammatory processinflammatory process – increasing – increasing intracellular calcium concentration intracellular calcium concentration causing fluid shift into muscle fiberscausing fluid shift into muscle fibers

After 8 hoursAfter 8 hours irreversible muscle irreversible muscle changeschanges

DiagnosisDiagnosis

The 6 P’s:The 6 P’s: PulselessnessPulselessness PallorPallor ParalysisParalysis Pain with passive stretchPain with passive stretch Paresthesia/hypoesthesiaParesthesia/hypoesthesia Palpably tense compartmentPalpably tense compartment

““Pain and the aggravation of pain by Pain and the aggravation of pain by passive stretching of the muscles in passive stretching of the muscles in the compartment in question are the the compartment in question are the

most sensitive (and generally the only) most sensitive (and generally the only) clinical finding before the onset of clinical finding before the onset of

ischemic dysfunction in the nerves and ischemic dysfunction in the nerves and muscles.”muscles.”

Whitesides AAOS 1996Whitesides AAOS 1996

Pain Pain – most important. Especially pain out of – most important. Especially pain out of proportion to the injury (child becoming proportion to the injury (child becoming more and more restless /needing more more and more restless /needing more analgesia)analgesia)

Most reliable signsMost reliable signs are pain on passive are pain on passive stretching and pain on palpation of the stretching and pain on palpation of the involved compartmentinvolved compartment

Other features like pallor, pulselessness, Other features like pallor, pulselessness, paralysis, paraesthesia etcparalysis, paraesthesia etc. appear very late . appear very late and we should not wait for these things.and we should not wait for these things.

Willis &Rorabeck OCNA 1990Willis &Rorabeck OCNA 1990

Important signsImportant signs Pain Pain on palpation of compartmenton palpation of compartment Tense compartmentTense compartment compared to other side compared to other side Pain on passive stretch across compartmentPain on passive stretch across compartment Sensory deficitSensory deficit of nerve traversing the of nerve traversing the

compartmentcompartment Muscle weaknessMuscle weakness Normal capillary refillNormal capillary refill Compartment syndrome seen in open tibias 6-Compartment syndrome seen in open tibias 6-

9% 9% --Blick--Blick

Beware of epidural analgesiaBeware of epidural analgesiaStrecker JBJS 1986Strecker JBJS 1986Morrow J. Trauma 1994Morrow J. Trauma 1994

Beware long acting nerve blocksBeware long acting nerve blocksHyder JBJS Br 1995Hyder JBJS Br 1995

Beware of controlled intravenous Beware of controlled intravenous opiate analgesiaopiate analgesia

Differential DiagnosisDifferential Diagnosis

Arterial occlusionArterial occlusion

Peripheral nerve injuryPeripheral nerve injury

Muscle ruptureMuscle rupture

Pressure MeasurementsPressure Measurements

Suspected compartment syndromeSuspected compartment syndrome Equivocal or unreliable examEquivocal or unreliable exam Clinical adjunctClinical adjunct ContraindicationContraindication

– Clinically evident compartment syndromeClinically evident compartment syndrome

Pressure measurementsPressure measurements

MubarakMubarak -- Fasciotomy when >30- -- Fasciotomy when >30-40mmHg40mmHg

Matsen Matsen -- >45 mmHg developed ACS-- >45 mmHg developed ACS WhitesidesWhitesides -- Fasciotomy when within -- Fasciotomy when within

20mmHg of DBP20mmHg of DBP McQueenMcQueen -- Fasciotomy when within -- Fasciotomy when within

30mmHg of DBP30mmHg of DBP HeppenstallHeppenstall – within 40mmHg (MAP- – within 40mmHg (MAP-

compartment pressurescompartment pressures

Pressure MeasurementsPressure Measurements

InfusionInfusion– manometermanometer– salinesaline– 3-way stopcock3-way stopcock

CatheterCatheter– wickwick– slit wickslit wick

----Whitesides, CORR Whitesides, CORR 19751975

Arterial line16 - 18 ga. Needle (5-19 mm Hg higher)transducermonitor

Stryker deviceSide port needle

Pressure MeasurementsPressure Measurements

Arterial lineArterial line– Zero at the level of the affected limbZero at the level of the affected limb

Pressure MeasurementsPressure Measurements

Simple Needle18 gaugeLeast accurateUsually gives falsely higher reading

Slit Catheter and Side ported needle

No significant differenceMore accurate

Moed et al JBJS 1993Moed et al JBJS 1993

MeasurementsMeasurements must be made in all must be made in all compartmentscompartments

Anterior and deep posteriorAnterior and deep posterior are usually are usually highesthighest

MeasurementMeasurement made within 5 cm of fractures made within 5 cm of fractures Marginal readingsMarginal readings must be followed with must be followed with

repeat physical exam and repeat repeat physical exam and repeat compartment pressure measurementcompartment pressure measurement

Heckman, WhitesidesHeckman, Whitesides JBJS 1994JBJS 1994

SUSPECTED COMPARTMENT SUSPECTED COMPARTMENT SYNDROMESYNDROME

Unequivocal + FindingsUnequivocal + Findings

FASCIOTOMYFASCIOTOMY

Pt. not Pt. not alert/polytrauma/unconciousalert/polytrauma/unconcious

Comp. pressure measurementComp. pressure measurement

within 30 mm Hg >30 mm Hg within 30 mm Hg >30 mm Hg of DBPof DBP

Serial exams Serial exams

FASCIOTOMYFASCIOTOMYMcQueen JBJSB 1996

Compartment SyndromeCompartment SyndromeEmergent TreatmentEmergent Treatment Remove castRemove cast or dressing or dressing Place at level of heartPlace at level of heart

(DO NOT ELEVATE(DO NOT ELEVATE as elevation reduces as elevation reduces the arterial inflow and the arterio-venous the arterial inflow and the arterio-venous pressure gradient pressure gradient

Alert ORAlert OR and Anesthesia and Anesthesia Medical treatment- Medical treatment- Supplemental oxygen Supplemental oxygen

administrationadministration Ensure patient is normotensiveEnsure patient is normotensive

Medical ManagementMedical Management

Compartmental pressure falls by 30% when Compartmental pressure falls by 30% when cast is split on one sidecast is split on one side

Falls by 65% when the cast is spread after Falls by 65% when the cast is spread after splitting. splitting.

Splitting the padding reduces it by a further Splitting the padding reduces it by a further 10% and complete removal of cast by 10% and complete removal of cast by another 15% another 15%

Total of 85-90% reduction by just taking off Total of 85-90% reduction by just taking off the plaster!the plaster!

Garfin, Mubarak JBJS 1981

Threshold for Threshold for FasciotomyFasciotomy

116 pts with tibial diaphyseal fx had 116 pts with tibial diaphyseal fx had continuous monitoring of anterior continuous monitoring of anterior compartment pressure for 24 hourscompartment pressure for 24 hours– 53 pts had ICP over 30 mmHg53 pts had ICP over 30 mmHg– 30 pts had ICP over 40 mmHg30 pts had ICP over 40 mmHg– 4 pts had ICP over 50 mmHg 4 pts had ICP over 50 mmHg

McQueen, Court-Brown JBJS Br 1996McQueen, Court-Brown JBJS Br 1996

Only 3 had Only 3 had Delta pr(DBP-ICP)Delta pr(DBP-ICP) of < 30, of < 30, they had they had FasciotomyFasciotomy

None of the patients had any sequalae None of the patients had any sequalae of the compartment syndrome of the compartment syndrome

DecompressionDecompression should be performed if should be performed if the differential pressure level drops to the differential pressure level drops to under 30 mmHgunder 30 mmHg

Surgical TreatmentSurgical Treatment

Fasciotomy,Fasciotomy, Fasciotomy, Fasciotomy, Fasciotomy, Fasciotomy,

– All compartments !!!All compartments !!!

Compartment SyndromeCompartment SyndromeSurgical TreatmentSurgical Treatment

Fasciotomy - prophylactic release of Fasciotomy - prophylactic release of pressure before permanent damage pressure before permanent damage occurs. Will not reverse injury from occurs. Will not reverse injury from trauma.trauma.

Fracture care – stabilization Fracture care – stabilization – Ex-fixEx-fix– IM NailIM Nail

Compartment SyndromeCompartment SyndromeIndications for FasciotomyIndications for Fasciotomy

Unequivocal clinical findingsUnequivocal clinical findings Pressure within 15-20 mm hg of DBPPressure within 15-20 mm hg of DBP Rising tissue pressureRising tissue pressure Significant tissue injury or high risk ptSignificant tissue injury or high risk pt > 6 hours of total limb ischemia> 6 hours of total limb ischemia Injury at high risk of compartment syndromeInjury at high risk of compartment syndrome CONTRAINDICATION - CONTRAINDICATION -

Missed compartment syndrome (>24-Missed compartment syndrome (>24-48 hrs)48 hrs)

Fasciotomy PrinciplesFasciotomy Principles

Make early diagnosisMake early diagnosis LongLong extensile incisions extensile incisions Release all fascial compartmentsRelease all fascial compartments Preserve neurovascular structuresPreserve neurovascular structures Debride necrotic tissuesDebride necrotic tissues Coverage within 7-10 daysCoverage within 7-10 days

Compartment SyndromeCompartment SyndromeLower LegLower Leg

4 compartments4 compartments

– Lateral: Peroneus longus Lateral: Peroneus longus and brevisand brevis

– Anterior: EHL, EDC, Tibialis Anterior: EHL, EDC, Tibialis anterior, Peroneus tertiusanterior, Peroneus tertius

– Supeficial posterior-Supeficial posterior-Gastrocnemius, SoleusGastrocnemius, Soleus

– Deep posterior-Tibialis Deep posterior-Tibialis posterior, FHL, FDLposterior, FHL, FDL

•.  

Single IncisionSingle Incision Perifibular FasciotomyPerifibular Fasciotomy

– Matsen et al (1980)Matsen et al (1980)– Single incision just Single incision just

posterior to fibulaposterior to fibula– Common peroneal nerveCommon peroneal nerve

Double IncisionDouble Incision

In most instances it In most instances it affords better exposure of affords better exposure of the four compartmentsthe four compartments

2 vertical incisions separated 2 vertical incisions separated by minimum 8 cmby minimum 8 cm

One incision over anterior and One incision over anterior and lateral compartmentslateral compartments

Superficial peroneal nerveSuperficial peroneal nerve One incision located One incision located

1-2 cm behind postero1-2 cm behind postero-medial aspect of tibia-medial aspect of tibia

Saphenous nerve and veinSaphenous nerve and vein Mubarak et al JBJS 1977

Fasciotomy: Medial LegFasciotomy: Medial Leg

Flexor digitorum longus

Gastroc-soleus 

Fasciotomy: Lateral LegFasciotomy: Lateral Leg

Superficial peroneal nerve

Intermuscular septum

Look for Superficial Look for Superficial Peroneal NervePeroneal Nerve

Superficial peroneal nerve Superficial peroneal nerve exits from lateral compartment exits from lateral compartment about 10 cm above lateral about 10 cm above lateral malleolus and courses into the malleolus and courses into the anterior compartment anterior compartment

Risk of injuryRisk of injury

Perif ibularPerif ibular

Posterior to fibular headPosterior to fibular head to just above to just above Lat malleolusLat malleolus

Expose and protect Common Expose and protect Common Peroneal Nerve proximallyPeroneal Nerve proximally

More difficult to decompress deep More difficult to decompress deep compartmentcompartment

Anterior insicion mobilized around Anterior insicion mobilized around fibula decompress ant/lat fibula decompress ant/lat compartmentscompartments

Two - IncisionTwo - Incision

11stst incision incision placed half – way between placed half – way between tibia crest and fibulatibia crest and fibula

Transverse facsia incision to identify Transverse facsia incision to identify the intermuscular septumthe intermuscular septum

Watch out for superficial peroneal Watch out for superficial peroneal nerve close to the septumnerve close to the septum

22ndnd incision incision posteromedial approach posteromedial approach -2cm posterior to posteromedial -2cm posterior to posteromedial margin of tibiamargin of tibia

Avoids saphenous nerve/vein Avoids saphenous nerve/vein

Use a Generous IncisionUse a Generous Incision

Lengthening the skin incisions to an average Lengthening the skin incisions to an average of of 16 cm16 cm decreases intra compartmental decreases intra compartmental pressures significantly. pressures significantly.

The skin envelope is a contributing factor in The skin envelope is a contributing factor in acute compartment syndromes of the leg acute compartment syndromes of the leg and The use of generous skin incisions is and The use of generous skin incisions is supported supported

Cohen, Mubarak JBJS Br 1991

Compartment SyndromeCompartment SyndromeForearmForearm

Anatomy-3 compartmentsAnatomy-3 compartments– Mobile wad-Mobile wad-

BR,ECRL,ECRBBR,ECRL,ECRB– Volar-Superficial and deep Volar-Superficial and deep

flexorsflexors– Dorsal-ExtensorsDorsal-Extensors– Pronator quadratus Pronator quadratus

described as a separate described as a separate compartmentcompartment

Forearm FasciotomyForearm Fasciotomy

Volar-Henry Volar-Henry approachapproach– Include a carpal Include a carpal

tunnel releasetunnel release Release lacertus Release lacertus

fibrosus and fasciafibrosus and fascia Protect median Protect median

nerve, brachial nerve, brachial artery and tendons artery and tendons after releaseafter release

Forearm FasciotomyForearm Fasciotomy

Protect median Protect median nerve, brachial nerve, brachial artery and tendons artery and tendons after releaseafter release

Consider dorsal Consider dorsal releaserelease

Hand FasciotomyHand Fasciotomy Interosseous muscles surrounded by Interosseous muscles surrounded by

investing fascia - not a true compartmentinvesting fascia - not a true compartment Dorsal incisionsDorsal incisions along 2 along 2ndnd and 4 and 4 thth MC MC

releasing on both sides and deep bluntlyreleasing on both sides and deep bluntly Can reach the adductor compartment via Can reach the adductor compartment via

22ndnd MC incision MC incision Thenar radial side of thumbThenar radial side of thumb Hypothenar ulnar side of 5Hypothenar ulnar side of 5 thth MC MC

Compartment SyndromeCompartment SyndromeHandHand

non specific aching non specific aching of the handof the hand

disproportionate disproportionate painpain

loss of digital loss of digital motion & continued motion & continued swellingswelling– MP extension MP extension

and PIP flexionand PIP flexion difficult to measure difficult to measure

tissue pressuretissue pressure

10 separate osteofascial 10 separate osteofascial compartmentscompartments– dorsal interossei (4) dorsal interossei (4) – palmar interossei (3)palmar interossei (3)– thenar and hypothenar thenar and hypothenar

(2)(2)– adductor pollicis (1)adductor pollicis (1)

Fasciotomy of HandFasciotomy of Hand

Finger fasciotomyFinger fasciotomy

Investing fascia supported by tough Investing fascia supported by tough volar skinvolar skin

Compartmentalize at flexion creasesCompartmentalize at flexion creases

Ulnar side index, long, and ring fingerUlnar side index, long, and ring finger

Radial side thumb and smallRadial side thumb and small

Spares dorsal digital nerve branchesSpares dorsal digital nerve branches Make incision at neutral axis of motion - Make incision at neutral axis of motion -

where flexor creases endwhere flexor creases end Over distal phalanx close to nailOver distal phalanx close to nail

Compartment SyndromeCompartment SyndromeFootFoot

9 compartments9 compartments– Medial, Superficial, Lateral, Medial, Superficial, Lateral,

CalcanealCalcaneal– Interossei(4), AdductorInterossei(4), Adductor

Careful exam with any swellingCareful exam with any swelling Clinical suspicion with certain Clinical suspicion with certain

mechanisms of injury mechanisms of injury – Lisfranc fracture dislocationLisfranc fracture dislocation– Calcaneus fractureCalcaneus fracture

Foot FasciotomyFoot Fasciotomy Traditionally five compartments (Traditionally five compartments (lateral, lateral,

medial, central, interosseous, and medial, central, interosseous, and calcaneal)calcaneal)

Two dorsal incisionsTwo dorsal incisions over 2 over 2ndnd and 4 and 4 thth MT MT– Releases interossei and adductorReleases interossei and adductor

Medial incisionMedial incision – 3cm from plantar – 3cm from plantar surface, 4cm from posterior heelsurface, 4cm from posterior heel– Subsequent released sup. and inf. Subsequent released sup. and inf.

Exposing plantar aponeurosis and gets Exposing plantar aponeurosis and gets abductor hallucis, calcaneal comartment, abductor hallucis, calcaneal comartment, digiti quintidigiti quinti

Dorsal incisionDorsal incision -to release the -to release the interosseous and adductorinterosseous and adductor

Medial incisionMedial incision -to release the -to release the medial, superficial lateral and medial, superficial lateral and calcaneal compartmentscalcaneal compartments

Compartment SyndromeCompartment SyndromeFootFoot

Compartment SyndromeCompartment SyndromeThighThigh

Lateral to release Lateral to release anterior and anterior and posterior posterior compartmentscompartments

May require medial May require medial incision for adductor incision for adductor compartmentcompartment

Lateral septum

Vastus lateralis

Delayed FasciotomyDelayed FasciotomyIs it Safe?Is it Safe?

– infection rate of 46% and amputation rate of 21% infection rate of 46% and amputation rate of 21% after a delay of 12 hours after a delay of 12 hours

– 4.5 % complications for early fasciotomies and 4.5 % complications for early fasciotomies and 54% for delayed ones 54% for delayed ones

RecommendationsRecommendations– If the CS has existed for more than 8-10 hrs, If the CS has existed for more than 8-10 hrs,

supportive treatment of acute renal failure should supportive treatment of acute renal failure should be considered.be considered.

– Skin is left intact and late reconstructions maybe Skin is left intact and late reconstructions maybe planned.planned.

Sheridan, Matsen.JBJS Sheridan, Matsen.JBJS 19761976

Delayed FasciotomyDelayed FasciotomyIs it Safe?Is it Safe?

– 5 pts, nine fasciotomies in lower limbs 5 pts, nine fasciotomies in lower limbs – Avg delay 56 h. (35-96 hrs). Avg delay 56 h. (35-96 hrs). – 1 pt died of septicaemia and multi organ 1 pt died of septicaemia and multi organ

failure, the others required amputationsfailure, the others required amputations RecommendationsRecommendations: :

– In delayed cases, routine fasciotomy may In delayed cases, routine fasciotomy may not be successful not be successful

Finkelstein et al. J Trauma 1996Finkelstein et al. J Trauma 1996

Wound ManagementWound Management After the Fasciotomy, a bulky compression dressing After the Fasciotomy, a bulky compression dressing

and a splint are applied.and a splint are applied. ““VAC” (Vacuum Assisted Closure) can be usedVAC” (Vacuum Assisted Closure) can be used Foot should be placed in neutral to prevent equinus Foot should be placed in neutral to prevent equinus

contracture. contracture. Incision for the Fasciotomy usually can be closed after Incision for the Fasciotomy usually can be closed after

three to five daysthree to five days

Interim Coverage Interim Coverage TechniquesTechniques

Simple absorbent Simple absorbent dressingdressing

Semipermeable Semipermeable skin-like membraneskin-like membrane

Vessel loop Vessel loop “bootlace”“bootlace”

““VAC” (Vacuum VAC” (Vacuum Assisted Closure)Assisted Closure)

Wound ManagementWound Management Wound is not closed at initial surgeryWound is not closed at initial surgery Second look debridement with consideration Second look debridement with consideration

for coverage after 48-72 hrsfor coverage after 48-72 hrs– Limb should not be at risk for further swellingLimb should not be at risk for further swelling– Pt should be adequately stabilized Pt should be adequately stabilized – Usually requires skin graftUsually requires skin graft – DPC possible if residual swelling is minimalDPC possible if residual swelling is minimal– Flap coverage needed if nerves, vessels, or bone Flap coverage needed if nerves, vessels, or bone

exposedexposed Goal is to obtain definitive coverage within 7-10 Goal is to obtain definitive coverage within 7-10

daysdays

Wound ClosureWound Closure

STSGSTSG Delayed primary Delayed primary

closure with relaxing closure with relaxing incisionsincisions

Complications Related to Complications Related to FasciotomiesFasciotomies

Altered sensation within the margins of the wound (77%) Altered sensation within the margins of the wound (77%) Dry, scaly skin (40%) Dry, scaly skin (40%) Pruritus (33%) Pruritus (33%) Discolored wounds (30%) Discolored wounds (30%) Swollen limbs (25%) Swollen limbs (25%) Tethered scars (26%) Tethered scars (26%) Recurrent ulceration (13%) Recurrent ulceration (13%) Muscle herniation (13%) Muscle herniation (13%) Pain related to the wound (10%) Pain related to the wound (10%) Tethered tendons (7%)Tethered tendons (7%)

Fitzgerald, McQueen Br J Plast Surg Fitzgerald, McQueen Br J Plast Surg 20002000

Complications related to Complications related to CSCS

Late SequelaeLate Sequelae Volkmann’s contractureVolkmann’s contracture Weak dorsiflexorsWeak dorsiflexors Claw toesClaw toes Sensory lossSensory loss Chronic painChronic pain AmputationAmputation

SummarySummary

Keep a high index of suspicionKeep a high index of suspicion Treat as soon as you suspect CSTreat as soon as you suspect CS If clinically evident, do not measure If clinically evident, do not measure Fasciotomy Fasciotomy

– Reliable, safe, and effectiveReliable, safe, and effective– The only treatment for compartment The only treatment for compartment

syndrome, syndrome, when performed in timewhen performed in time

VOLKMANN’S ISCHAEMIC VOLKMANN’S ISCHAEMIC CONTRACTURESCONTRACTURES

Contracture results from insufficient arterial perfusion & Contracture results from insufficient arterial perfusion & venous stasis followed by ischemic degeneration of venous stasis followed by ischemic degeneration of muscle;muscle;

             - irreversible muscle necrosis begins after 4-6 hrs;- irreversible muscle necrosis begins after 4-6 hrs;

                      - Resulting edema impairs circulation, leads to - Resulting edema impairs circulation, leads to forearm forearm comapartmentcomapartment syndrome syndrome, which propagates , which propagates progressive muscle necrosis;progressive muscle necrosis;

                      - Muscle degeneration is most affected at the - Muscle degeneration is most affected at the middle third of muscle belly, being most severe closer middle third of muscle belly, being most severe closer to bone;to bone;

      

    - - There is less involvement toward the There is less involvement toward the proximal & distal surfaces;proximal & distal surfaces;

                      - Necrosis of the muscle with - Necrosis of the muscle with secondary fibrosis that may develop secondary fibrosis that may develop followed by calcification in its final followed by calcification in its final phasephase

AnatomyAnatomy                       - distal to Lacertus fibrosus --Brachial - distal to Lacertus fibrosus --Brachial

artery branches into Radial & Ulnar artery.artery branches into Radial & Ulnar artery.

                      - Radial artery is superficially located, - Radial artery is superficially located, whereas ulnar artery is deeply situated, whereas ulnar artery is deeply situated, traversing deep to pronator teres muscles.traversing deep to pronator teres muscles.

                      - Ulnar artery gives rise to the common - Ulnar artery gives rise to the common interosseous artery, which divides immediately interosseous artery, which divides immediately into anterior & PIN branches.into anterior & PIN branches.

                      - Flexor digitorum longus and the Flexor - Flexor digitorum longus and the Flexor pollicis longus muscles derive their blood pollicis longus muscles derive their blood supply thru anterior interosseous artery.supply thru anterior interosseous artery.

PathoanatomyPathoanatomy

                    - Infarct has ellipsoid shape with its axis along - Infarct has ellipsoid shape with its axis along anterior interosseous artery & its central point slightly anterior interosseous artery & its central point slightly above middle of the forearmabove middle of the forearm

                      - Therefore, the muscles most dependent on - Therefore, the muscles most dependent on the Anterior Interosseous artery (FDP, FPL, FDS, and the Anterior Interosseous artery (FDP, FPL, FDS, and the pronator teresthe pronator teres

                        - FDP and FDS muscles become contracted - FDP and FDS muscles become contracted and are replaced by scar, which leads to wrist flexion and are replaced by scar, which leads to wrist flexion contracture and clawing of the fingerscontracture and clawing of the fingers

                        - In addition to muscle necrosis, there will also - In addition to muscle necrosis, there will also be injury to the Median and Ulnar nerves leading to be injury to the Median and Ulnar nerves leading to High Ulnar nerve and Median nerve palsyHigh Ulnar nerve and Median nerve palsy                      

FingersFingers

                                    - may lie in intrinsic minus - may lie in intrinsic minus position (due to high nerve palsy)position (due to high nerve palsy)                  - alternatively, the fingers                   - alternatively, the fingers may lie in an intrinsic plus position may lie in an intrinsic plus position (MP's flexed, PIP extended), if there (MP's flexed, PIP extended), if there has been a concomitant  compartment has been a concomitant  compartment syndrome of the hand resulting in syndrome of the hand resulting in intrinsic contracture intrinsic contracture