Compartment Syndrome

Compartment Syndrome is the condition that increases the pressure within a limited space and compromises the circulation and function of tissue within that space

Predominantly Involves:

1. Volar component of the forearm (Volkmann’s Ischemia)
2. Anterior compartment of leg ( Anterior tibial Syndrome)

Causes of Compartment Syndrome

Pathophysiology

Clinical Presentations

Investigations

• Doppler USG

• RFT: Urea/ Creatinine

• Urine for myogobinuria

Diagnosis

Clinical diagnosis is more important than measurement

Normal tissue pressure: 0-4 mmHg

And on exertion, it increases to 8-10 mmHg

Certain indications for Intra-compartmental measurements:

• Unresponsive patients
• Uncooperative patients
• Patient with peripheral nerve defect

Method of measurements

See also: Whitesides 3-way stop clock method

Absolute pressure increase

• 30mmHg (Mubarak)
• 45mmHg (Matsen)

Where to measure

Current Recommendation for established diagnosis of compartment syndrome

1. Univocal clinical finding of compartment syndrome
2. Compartment pressure within 20 mmHg of diastolic blood pressure and within 30mmHg of mean arterial pressure(MAP)
3. Steadily rising compartment pressure on serial examination
4. Significant tissue injury in the appropriate clinical setting
5. More than 6 hr of total limb ischemia

Treatment of Compartment Syndrome

Preventive measures

• Removal of cast or occlusive dressing around the entire circumference
• Affected limb, place in the heart level. The elevation is contraindicated as it decreases arterial blood flow and narrows the arterial-venous pressure gradient and worsens ischemia
• Ensure patient remains normotensive as hypotension reduces perfusion pressure and facilitates tissue injury
• Additional trauma due to reduction, distraction, and reaming should be avoided
• Keep knee in extension (Flexion kinks popliteal vein) and foot in normal plantar flexion ( dorsiflexion increases in the posterior compartment)
• Cooling measures
• Medical therapy has no role

Surgical decompression

Mubarak recommended fasciotomy can be performed in

Normotensive patient with positive clinical findings:

• Compartment pressure > 30 mmHg

• The duration of increased pressure is unknown and thought to be > 8 hr

Hypotension patient with compartment pressure > 20 mmHg

Uncooperative unconscious patient with compartment pressure > 30mmHg

Clinical signs such as demonstrable motor and sensory loss

Interrupted arterial circulation to be extremity for > 4 hr

URGENT

The entire fascia envelop should be split over a wide area

Allow all muscles within the compartment to protrude (fasciotomy)

If distal pulses do not present main artery proximally must be inspected

Marked narrowing of vessels due to persistent spasm

then, infiltration of papaverine which relaxes arterial muscle wall needs (15-20 min to become apparent)

If fails may be due to a thrombus

May need thrombectomy, arteriotomy

The artery may get compressed by a bone fragment which should be corrected and soft tissue release carried out

Need to explore and decompress the major nerve, depends upon the degree of neuro deficit

Fascia left open, Secondary closure by skin graft after swelling subsided

Post-fasciotomy Wound care

In Tibia, 3 decompression techniques are used:

1. Fibulectomy
2. Perifibular fasciotomy
   • With a single lateral incision just posterior to the fibula, it becomes difficult to decompress the posterior compartment
3. Double incision fasciotomy
   • Posteromedial + Anterolateral
   • The interval between anterolateral to 1-2cm behind the posteromedial aspect of the tibia is separated by 8 cm

In the arm, the anterior compartment is decompressed using medial incision and the posterior compartment is decompressed using lateral incision. The radial and ulnar nerves passed through both the compartment so both incisions are necessary to decompress each one of the nerves.

Foot Compartment Syndrome

Anatomy: 9 main compartments (Placed in 4 groups)

Medial

• Abductor Hallucis
• Flexor hallucis brevis

Lateral

• Abductor digiti minimi
• Flexor digiti minimi brevis

Interosseous (4)

Central (3)

• Superficial
  • Flexor digitorum brevis
• Central
  • Quadratus Plantae
• Deep
  • Adductor hallucis
  • Posterior tibial neurovascular bundle

Treatment Options

Nonoperative

Examination not consistent with compartment syndrome

Operative

Emergency foot fasciotomy

Indications:

• Clinical presentation consistent with compartment syndrome
• Compartment measurement with absolute value 30-45 mmHg
• Compartment measurement within 30 mmHg of diastolic blood pressure

Surgical techniques

Emergency fasciotomy of all compartments

Dual dorsal incision

• Dorsal medial incision (medial to 2^nd metatarsal: releases 1st and 2nd metatarsals)
• Dorsal lateral incision (lateral to 4th metatarsal: between 3^rd/ 4^th intersosseoi)

Add medial incision to decompress calcaneal compartment

The medial and dorsal approaches are commonly used. The median approach affords access to all four compartments of the foot and is made along the plantar border of first metatarsal.

Complications

• Chronic pain and hypersensitivity
• Fixed flexion deformity of digits

See also: Chronic Compartment Syndrome