Compartment Syndrome

Definition

 

Circulation of tissues within a closed osteofascial space are compromised by increased pressure within that space

 

Most common 

- anterior leg compartment

- flexor compartment forearm

- deep posterior leg compartment

 

Aetiology

 

Prerequisite is volume restricting envelope 

- fascia & skin

- POP

- dressings

 

1.  Increased contents

 

Bleeding / edema 

- fracture

- osteotomies 

- crush injuries

- post - ischaemic swelling

 

2.  Decreased size

 

Tight casts & dressings

Tight closure of fascial defects

Fracture reduction 

 

Pathogenesis

 

Increased local tissue pressure increases pressure within intracompartmental veins

- local AV gradient is reduced

- causes decreased local perfusion secondary to Starling Forces

 

Metabolic tissues demands not met

- loss of tissue function & viability

- distal pulses remain as ICP < SBP 

- digit capillary refill remains as venous return extracompartmental 

 

Symptoms

 

1. Pain

- most important sign

- much great than expected 

- masked by coma / neural injury 

- unrelieved by opiates

 

2. Paraesthesia

- often early

- pins & needles or decreased sensation to light touch

- distribution important

- nerve of that compartment will be affected

 

Signs

 

3. Palpation

- swollen, tense compartment

 

4. Passive Stretch

- pain on passive stretch 

- subjective

- complicated by underlying trauma

 

5. Paresis

- may be due to proximal nerve injury or guarding 2° to pain

 

6. Pulses

- pulse & capillary refill are normally present

 

Diagnosis

 

Clinical Diagnosis

 

Tense compartment with pain +++

Pain on passive stretch

 

Intramuscular Pressure Measurement

 

Pressure Measurement

 

Indications

 

1. Unresponsive 

- head injury

- ventilated

2. Uncooperative 

- children, drug abusers

3. Underlying peripheral nerve deficit 

- tibial fracture with CPN nerve deficit

 

Techniques

 

1. Needle - Manometer Method (Whitesides)

- 18G needle is connected via a 3 way stop cock to an air filled 20 ml syringe

- air filled tubing which is connected to a Hg Manometer 

- a small amount of saline sits in tube connected to needle 

- compression of the syringe raises the pressure till saline flows into the compartment

- this is indicated by the meniscus moving

 

2.  Arterial Pressure Transducer

- i.e. devices used in ICU to measure arterial blood pressure and CVP

- no need to inject fluid

- pressure in saline tube equalizes with compartment

- connect to Wick or Slit catheter

- slits have many longitudinal slits to equalize pressure in tube with compartment

 

3.  Stryker Device 

- Variation on 2

 

Interpretation

 

Matsen > 45 mmHg

Mubarek & Rorabeck > 30 mmHg

Whitesides - within 30mmHg of DBP

 

Management

 

Prevention 

 

Remove all tight dressings

- splitting POP decreases pressure by 30%

- bivalving & cutting padding reduces pressure by another 55%

- elevate limb 

 

Avoid hypotension 

 

Ream without tourniquet

 

Early fasciotomy 

 

Compartment Release

 

Full-length skin incision

Complete fasciotomy of all compartments

Assessment of muscle (colour / consistancy / contraction / bleeding)

Debridement dead muscle

Delayed DPC / graft 

 

2 Incision Technique Leg

 

Anterolateral compartments

- incision halfway between crest of tibia & fibula

- identify and protect SPN

- expose lateral intermuscular septum (transverse cut)

- release Anterior & Lateral compartments

 

Posterior compartments

- incision 2 cm posterior to posterior margin of tibia

- identify and protect saphenous vein / nerve anteriorly

- identify septum between superficial & deep compartments

- release fascia over Gastro-Soleus (superficial posterior compartment)

- release deep posterior compartment which is located behind the tibia / FDL

 

Perifibular Approach / Single incision Technique

 

Lateral incision beginning just posterior to fibula

- expose & protect CPN

- posteriorly release superficial posterior compartment

- release FHL (deep posterior compartment

- anteriorly expose and release anterolateral compartments after identifying SPN

 

Compartment Release Forearm

 

4 interconnected compartments

- volar superficial

- volar deep (FDP / FPL / pronator quadratus)

- mobile wad (BR, ECRL, ECRB)

- extensor

 

Volar

- incision from medial elbow to carpal tunnel

- must release lacertus fibrosis and carpal tunnel

- divide fascia

- this will release superficial flexor muscles

- ensure release mobile wad

- ensure release FDP

 

Dorsal

- often volar release wil decompress dorsal compartment

- usually ulnar sided incision

- proximal over muscle belly

- distally is mostly tendons

 

Compartment Release Hand

 

Two dorsal incisions

- over MT 2 and MT 4

- release interossei compartments

 

Carpal tunnel incision

- release thenar / hypothenar / adductor

- release carpal tunnel

 

Compartment Release Foot

 

2 dorsal incisions

- over MT 2 and MT 4

- release 4 interossei compartments

 

Medial incision

- release medial / central and lateral compartments

 

Complication

 

Volkmann's contracture

- ischaemic muscles fibrose & contract

- causes deformity & stiffness

- nerves damaged with variable numbness