Compartment Syndrome

Overview

Prof. Mamoun Kremli

Objectives

• Pathophysiology and causes
• Clinical Picture
• Identification
• Treatment

Pathophysiology

Key Factors

• Increasing volume in a closed compartment
• Pressure increased in compartment
• Decreasing arteriovenous difference
• Hypoxia
  • Dec. in blood supply
• Irreversible muscle and nerve damage

PathophysiologyZ

Causes

• Hematoma

  • Fracture hematoma
  • Soft tissue trauma
  • Arterial injury
  • Bleeding disorders - hemophelia**

• Surgery

  • Post osteotomy (Tibia / Forearm)
  • Circumferential tight dressings/ casting

• Extravasation of IV infusion the fluid go to the soft tissue

• Burns

• Post-ischemic swelling (reperfusion)

Clinical Picture - 5P s

→ TREAT

• Pain out of proportion& expectation/ burst sensation
  • passive motion / stretch → Pain is Increase
• Palpable tense swelling
• Paresthesia

→ too late, >8h

• Pallor
• Paralysis
• Pulselessness

Pain

• Absent in (high-risk patients):
  • Altered consciousness because of Pain, ICU
  • Children (unable to verbalize) follow the response of analgesia
  • Concomitant nerve damage
  • Clinical picture equivocal
  • Polytrauma (Multiple injuries) patient
  • Sedated patient or Epidural anesthesia

Clinical Picture - Look

• Shiny Swelling of compartment
• Pallor / or Dusky skin
• Blisters
  • Clear fluid
  • serosanguinous: severe
  • Bloody: worst

Clinical Picture - Feel

• Tense
• Tender
• Paresthesia
• Weak Pulse ?
  • Too late

Clinical Picture - Move

• Pain on passive stretch
  • Passive dorsiflexion of ankle (leg)
  • Passive dorsiflexion of wrist (forearm)

Diagnosis

Open fractures DO NOT decompress an elevated compartment pressure could be open fracture but the opening not enough so it have compartment.

• High index of suspicion
• Diagnosis is clinical:
  • Unrelenting bursting pain
  • Not relieved by analgesia
  • Swollen compartment
  • Pain on passive stretching
  • Sensory deficit?
  • Pulses always palpable

Management

• ABC’s.
• Correct hypotension
• Supplemental oxygen administration

If in cast:

• Bivalve down to skin or remove
• Remove circumferential bandages
• Raise limb at level of the heart
  • Higher elevation reduces the arterial inflow

Surgical Management

• Urgent. Should not be delayed
  • No response to medical management within one hour
• Fasciotomy
  • Skin and All compartments

Fasciotomy Indications

• High risk patients
  • Prophylactic with major corrective osteotomy of the leg & forearm
  • S&S not resolved within 30-60 min. of appropriate precautions
  • Significant tissue injury
  • Suspicion: Equivocal clinical findings
  • Based on measurements:
    • Delta pressure (DBP - compartment P.) $\le$ 25 mm Hg.
    • Compartment pressure > 30mm Hg.

Fasciotomy Principles

Key Principles

• Long skin incisions
• Release all compartments
  • open it all
• Debride necrotic muscles (4C’s):
  • color, consistency, contraction, circulation
    • pink, soft, capability to bias
    • not dark
    • criteria to access the muscle
• Preserve neurovascular structures
• Never close fascia, Keep wound open
  • fill the swelling subfida
• Repeated looks x48h as needed
• Coverage (within 3-5 days)

Visual Representation

Treatment -

early

• Color red
• Consistency normal
• Capable of bleeding
• Contracts when pinched

lateY

• Color dark
• Consistency abnormal
• Not bleeding
• No contractions when pinched

Fasciotomy Principles Continued

• No skin wound closure
• Bulky dressing with a splint
• V.A.C” dressing (Vacuum Assisted Closure)
• ? “Boot lace” vessel loop closure (gradual)

Late Stage Fasciotomy

• Later skin graft / flap:
  • Usually skin graft
  • Flap coverage needed if nerves, vessels, or bone exposed

Fasciotomy Contraindication

• Confirmed acute compartment syndrome diagnosis for > 48 hours

  • Damage cannot be reversed, and
  • High infection rate when dead tissues are exposed

• Already dead muscles, as in crush injuries

Complications of untreated C.S.

• Volkmann’s contracture :
  • Muscle weakness
  • Sensory loss
  • Chronic pain

Summary

• Compartment syndrome is a clinical diagnosis
• Should not be missed - Disaster
• Requires urgent management
  • If in doubt perform fasciotomy
• “Time” is the important factor to avoid irreversible complications
• Do NOT apply circumferential dressings