3. Objective
• To understand key definitions in compartment
• To have clear diagnostic plan
• To determine treatment options
• To understand complications and preventive
options
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4. Introduction
• ACS- is a surgical emergency where the ICP is elevated to a
level and for a duration that with out emergent fasciotomy
and decompression leads to muscle ischemia and necrosis.
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5. Terms
• Exersional CS : Elevation of ICP during exercise
• Volkmann ischemic C: is the end stage of
neglected ACS with irreversible muscle necrosis
leading to ischemic contractures .
• The crush syndrome is the systemic result of muscle
necrosis commonly caused by prolonged external
compression of an extremity
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6. History
• Richard Von Volkmann, 1881
• “for many years I have noted on occasion,
following the use of bandages too tightly
applied, the occurrence of paralysis and
contraction of the limb, NOT … due to the
paralysis of the nerve by pressure, but as a
quick and massive disintegration of the
contractile substance and the effect of the
ensuing reaction and degeneration”
6
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7. • In 1911 Bernhard Bardenheuer first considered
fasciotomy as a potential therapy, shortly before
JB murphy in 1914 suggested, that fasciotomy
should be used to relieve the pressure in
edematous extremities.
• PN Jepson established fasciotomy in 1926
• Finochietto started research on compartment
syndrome of upper limb in 1920, but the current
term "compartment syndrome" was not
established before 1963 by Reszel et al. from
mayo clinic
7
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8. • 1970 numerous investigators established the
pathophysiology of CS
• In 2005 data of computerized search of US
national pediatric trauma registry reported
85% of cases as a sequel to fractures, while
13% where STI
8
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9. Epidemiology
• 3.1 per 100,000 per annual among western
• 7.3 per 100000 in male and 0.7 per 100,000 in
female ( 10x increase)
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10. Etiology and Risk factor
• Most commonly fracture ( 69% in adult & 76%
in children) Tibia>>>> Distal radius>>>
forearm
• Soft tissue injury
• Male
• Adolescence/young more at risk { in tibia # 3x less in
age > 35 and 35X lower for distal radius in older
patient}
• Low energy >>>>> High energy
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11. • 61% of ACS of non-fracture in children is iatrogenic
• Non fracture ACS is more in older pt with associated
co-morbidity with M=F, use of anti-coagulant is also
risk factor
• Polytrauma patient risk for delay in dx so high
suspicious for risk factor
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12. Pathogenesis
I. Critical closing Pressure theory
• States there is CCP in the small vessels when
transmural pressure drops
• TM= IVP-Tissue P
• TM is moderated by constricting force governed by
smooth muscle on the walls
• States as the tissue pressure increase arteriolar
closure resulting blood flow to cease
• Critics claim ischemia is major trigger for
compensatory arteriole vasodilation
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13. II. Arteriovenous gradient Theory
• According to this theory the increases in local tissue
pressure reduce the local AV pressure gradient and
thus reduce the blood flow
• LBF = (Pa − Pv) ÷ R
• Most accepted
• Elevation of limb in presence of raised tissue further
decrease AV gradient
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14. III. Micro-vascular Occlusion Theory
• Postulate capillary occlusion is main stay for ACS
• Animal based study
• Claims capillary closure further capillary leaking and
further worsen tissue pressure
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15. Diagnosis of Acute Compartment Syndrome
Prompt diagnosis of ACS is the key to a successful
outcome.
Delay in diagnosis - single cause of failed ACS
treatment.
Clinical symptoms and signs and/or ICP monitoring
for the diagnosis.
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16. I. Clinical Diagnosis
pain on passive stretching(Sn-13%,Sp-97%)
Pain( progressive, not relieve with imm, refractory)
Pain out of proportion to the injury(Sn-13%,Sp-97%)
Paresthesia(Sn-13%,Sp-98%)
Paralysis
Pulselessness
Pallor
Absent capillary refill
poikilothermia
Tense swelling(Sn-54%, Sp-76%)
XR must be obtained to rule out Fx
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17. • Tissue survival
– Muscle
• 3-4hr reversible changes
• 6hrs- variable damage
• 8hrs- irreversible ischemia
• Central is most affected
• Some are more vulnerable
– Nerve
• 2hrs- looses nerve conduction
• 4hrs- neurapraxia
• 8hrs- irreversible changes
Effect on Bone
Non union
Psudo-arthrosis
Reperfusion Injury
After reestablishment of
blood flow to ischemic
muscle after fasciotomy
Due to inflammatory
response for muscle
breakdown like pro-
coagulant
If large muscle can result
systemic presentation
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18. Risk factors for delayed ACS Dx
Reliance on clinical signs alone
Children
Sedated pts
Patient controlled analgesia/regional anesthesia
Unconscious/obtunded pts
pts with Learning disabilities
Psychiatric pts
Pts with neurologic deficit
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19. Diagnostic performance of clinical Sxs & Sns
Employing a combination of clinical signs and symptoms
raises the Dxtic sensitivity.
Pain, pain on passive stretching, paresthesia and
paralysis utilized.
One positive sign has sensitivity of < 26 %.
To achieve a probability of > 90 %, 3 clinical findings
must be noted and the 3rd finding must be paresis.
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21. II. ICP measurement
Is the most sensitive and specific ACS Dxtic method
and considered confirmatory.
Invasive and non invasive methods are available.
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25. Technique of ICP measurement
Mark the proper entry site
Strict asepsis of entry site.
Needle entered perpendicular to skin.
Transducer placed level with the compartment
being measured.
Avoid placement of catheter at Fx site but within
5cm of Fx site.
Checking correct placement of catheter within
the desired compartment.
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26. Normal tissue compartment pressure
• Normal resting ICP is up to 10 mm Hg, but may
reach 18 mmHg and less than 20 mmHg is well
tolerated.
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27. ICP threshold for ACS Dx
Absolute ICP > 40mmHg
Delta(∆) P= DBP- ICP, value < 30mmHg
In children MAP is used instead of DBP
∆P is more has a better diagnostic performance.
Thresholds apply equally for anatomic areas other than
leg.
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31. • Both the time and severity is factor for fasciotomy
• Continuous ICP measurement is gold standard
• Persistent delta pressure <30 for more than 2 hrs is
indication to go for fasciotomy
• Fasciotomy should not be done with single
measurement unless in extreme cases
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32. Management principles
• Prepare OR
• Drape the patient – sterile technique
• Administer prophylactic antibiotics
• Make your skin incisions extensile
• Decompress all compartments
• May require individual epimysiotomy
• Debride obvious muscle necrosis at initial
operation
• Second look at 24 to 72 hours for muscles
vascularity uncertain
32
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33. Treatment
consists of decompression:
• Remove the tight bandage or plaster cast/spltting
and spreading
• Escharotomy (decompression of the skin)—in cases
of burns
• Fasciotomy
• Epimysiotomy (decompression of the connective
tissue between muscles and fascia)
• Limb should not be elevated above the level of heart
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34. Timing
• After 6-8hrs of decreased MPP muscle extensive
necrosis is inevitable
• Peripheral nerve will also have permanent functional
impairment
• After 8-10hrs infection risk is very high and
amputation is likely therefore decision for fasciotomy
should be done by most senior surgeon
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37. • Single incision fasciotomy with Vs without
fibulectomy
• Double Vs single incision fasciotomy
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38. Approach to Thigh CS
• Compartment syndrome of the thigh is a rare
but serious condition that may result in high
rate of morbidity and mortality.
• Limited resource
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45. Approach to forearm CS
• the forearm contains 3
compartments
• Volar
• Dorsal
• Mobile wad
45
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46. Standard Anterior dermato-faciotomy
1. Make anterior curvilinear
incision medial to biceps
tendon
2. Cross elbow flexion crease
at an angle
3. Divide bicipital aponeurosis
4. Go distally into palm to
allow carpal tunnel release,
but avoid wrist flexion
crease at right angle
5. Divide flexor retinaculum at
wrist
6. With scissors free the fascia
over superficial
compartment muscles
46
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47. Volar incision
5. Identify FCU and retract it
with its underlying ulnar NV
bundle medially
6. Retract FDS and median
nerve laterally to expose the
FDP in its deep
compartment
7. Check if its overlying fascia
or epimysium is tight, and
incise it longitudinally
8. Continue disection distally
by incising transverse carpal
ligament along the ulnar
border of PL and median
nerve
47
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48. Modified Anterior dermato-faciotomy
approach
• Extend over carpal tunnel and guyons canal ( for
Median and ulnar nerve decompression)
• As henrys approach
• If needed can cross AL of elbow
• Avoid incision over cubital fossa
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50. Dorsal incision
• Straight line 5cm distal to
lateral epicondyle between
EDC and ECRB and extend it
about 10 cm distally
• Gently undermine
subcutaneous tissue and
release fascia overlying
mobile wad of henry
Apply a sterile moist
dressing and a long-arm
splint. The elbow should
not be left flexed beyond
90 degree
50
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51. Hand decompression
• Two longitudinal incisions over 2nd and 4th
metacarpals. With this incisions we can decompress
dorsal and palmar interrossei , adductor
compartment
51
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53. • longitudinal incision radial side of 1st metacarpal
• decompresses thenar compartment
• longitudinal incision over ulnar side of 5th
metacarpal
• decompresses hypothenar compartment
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54. Hand decompression
54
• Incise the fascia, and release the compression
of the distended muscles by allowing them to
extrude into the wound if necessary.
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55. Hand decompression
55
• If the digit require decompression incision
made at mid axial plane on independent side.
– Ulnar side : middle , index and ring finger
– Radial side : little finger and thumb
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56. Post fasciotomy wound
• Pack wound loosely open with saline-dampened gauze
and apply a bulky dressing
• Never close incisions immediately after fasciotomy
• Second look at 24 to 72 hours for possible repeat
debridement
• Active and active-assisted ROM of adjacent joint on 2nd
day post op
• If split thickness skin graft, immoblize limb for 3-5 days
to decrease sheer forces across graft
• When graft incorporated, re-institute ROM
56
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57. Delayed surgical closure
• Fasciotomy wound is clean, fracture stabilized and
swelling subsided ( Closure in 3-7 days)
Elastic vessel loop
Skin graft
vacuum wound management
Immobilize with long splint/ don’t
Flex > 90
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58. Late diagnosis after 8-10 hrs?
• Finkelsein et al, conclued that sequel of
infection after delayed fasciotomy is worse
than the late muscle contracture due to the
fibrosis
• Sheridan and matsen reported an infection
rate of 46% and amputation rate of 21% after
late fasciotomy
• Sometimes, doing nothing is the treatment of
choice
58
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60. Summary
• ACS is orthopedic emergency
• Delayed or missed diagnosis can result in devastating
loss of function and limb loss
• Difficult in diagnosis in children, obtunded and
comatous patient, so high degree of suspision
• Decompression of all the compartments is the
mainstay of treatment
• Appropriate care should be given to post operative
wounds
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61. Reference
• Campbell’s operative orthopedics 11th Ed
• Rockwood and green’s fractures in adults 8th Ed
• Chapman’s orthopedic surgery 3rd edition
• Orthobullet 2021
• PubMed – publications
• Internet
3/11/2024 61
the elevation of intracompartmentalpressure during exercise, causing ischemia,pain, and rarely neurologic symptoms and signs. It is characterized
by resolution of symptoms with rest but may proceed to acute compartment syndrome if exercise continues
The crush syndrome is the systemic result of muscle necrosiscommonly caused by prolonged external compression of an
extremity. In crush syndrome muscle necrosis is established by
the time of presentation, but ICP may rise as a result of intracompartmental
edema, causing a superimposed acute compartment
syndrome.
Although larrey in 1812 and hamilton in 1850 gave some descriptions of CS, the first man to do publication was RVV who in 1881 said …
Used to believe high energy usually open is more associated with ACS but large eidnberg study show more associated with closed in 59% …… suggested that high energy disrupt each compartment fascia so gives autodecompression……. But low energy doesnot ………. Also for tibia 60 is gA type III but only 20% has ACS
Reason why young is with the same fascia layer has larger muscle bulk so low free space. Older atrophied muscle is protective also hypertension is also protective from ACS
In karge eidinburg study youth and being male has shown association of o.oo1 with ACS
The only exception for being young is soft tissue injury wher average age is 36 years and older than those with fracture
Base deficit… requirment for transfusion……high serum lactate is risk group in polytrauma
is a critical closing pressure in the small vessels when the transmural pressure (TM) (the difference between intravascular pressure and tissue pressure) drops.19 TM is balanced by a constricting force (TC) consisting of active and elastic tension derived from smooth muscle action in the vessel walls.
According to this theory the increases in local tissue pressure reduce the local AV pressure gradient and thus reduce the blood flow. When flow diminishes to less than the metabolic demands of the tissues (not necessarily to zero), then functional abnormalities result. The relationship between AV gradient and the local blood flow (LBF) is summarized in the
equation:LBF = (Pa − Pv) ÷ R
where Pa is the local arterial pressure, Pv is the local venous pressure, and R is the local vascular resistance. Veins are collapsible tubes and the pressure within them can never be less than the local tissue pressure. If tissue pressure rises as in the acute compartment syndrome, then the Pv must also rise, thus reducing the AV gradient (Pa − Pv) and therefore the local blood flow. At low AV gradients compensation from R is relatively ineffective62 and local blood flow is primarily determined by
the AV gradient. Matsen et al.92 presented results on humansubjects demonstrating reduction of the AV gradient with elevation of the limb in the presence of raised tissue pressure
Measurement of capillary pressure in dogs with normal tissue pressures revealed a mean level of 25 mm Hg. Hargens et al.52 suggested that a tissue pressure of similar value is sufficient to reduce capillary blood flow
Peripheral pulses and capillary return are always intact in ACS.
Absent peripheral pulses, pallor, and reduced capillary return are late clinical signs of ACS and will be associated with a vascular injury requiring an angiogram, or an established ACS where amputation is often inevitable. Conversely, it is dangerous to exclude the diagnosis of ACS because distal pulses are present. The pain is
Out of proportion
Progressive
Not relieved by immobilization
Present on passive muscle stretch
Refractory to analgesia
Pain – a subjective symptom can be reduced/unreliable
If there is concomitant nerve injury
Obtunded
Anesthesized
Children
4 cases of ACS without pain, diagnosis confirmed after fasciotomy
Badhe et al. the ‘silent compartment syndrome
Evidence indicates that muscle necrosis is present in its greatest extent centrally in the muscle, and that external evaluation of the degree of muscle necrosis is unreliable. The duration of muscle ischemia dictates the amount of necrosis, although some muscle fibers are more vulnerable than others to ischemia. For example, the muscles the anterior compartment of the leg contain type I fibers or red slow twitch fibers, whereas the gastrocnemius contains mainly type II or white fast twitch fibers. Type I fibers depend on oxidative metabolism of triglycerides for their energy source and are more vulnerable to oxygen depletion than type II fibers whose metabolism is primarily anaerobic.
The mechanism of damage to nerve is as yet uncertain and could result from ischemia, ischemia plus compression, toxic effects, or the effects of acidosis
caused obliteration of the “musculodiaphyseal” vessels and caused frequent pseudarthrosis.
Asyringe filled with air is attached to this column, as is a pressure manometer or transducer. The ICP is the pressure that is required to inject air into the tubing and flatten the meniscus between the saline and the air. This method was modified by Matsen et al. to allow infusion of saline into the compartment.90,91 The ICP is the pressure resistance to infusion of saline. These methods, although simple and inexpensive, have some drawbacks. A danger exists of too large a volume being infused, possibly inducing acute compartment syndrome. Itis probably the least accurate of the measurement techniques available, with falsely high values having been recorded in comparison with other technique. The wick catheter was first described for use in acute compartmentsyndrome by Mubarak et al.105 This is a modification of the needle technique, in which fibrils protrude from the bore of the catheter assembly. This allows a large surface area for measurement and prevents obstruction of the needle; it is ideal for continuous measurement. A disadvantage of this technique is the possibility of a blood clot blocking the tip or air in the column of fluid between the catheter and the transducer, which will dampen the response and give falsely low readings. There is a theoretical risk of retention of wick material in th
The slit catheter was first described by Rorabeck et al.127 This operates on the same principle as the wick catheter in that it is designed to increase the surface area at the tip of the catheter by means of being cut axially at the end of the catheter (Fig. 29-3). The interstitial pressure is measured through a
column of saline attached to a transducer. Patency can be confirmed by gentle pressure over the catheter tip; an immediate rise in the pressure should be seen. Care must be taken to avoid the presence of air bubbles in the system as this can, like the wick catheter, result in falsely low readings. The slit catheter is more accurate than the continuous infusion method104 and is as accurate as the wick catheter
Attempts to improve the reliability of ICP measurement ledto the placement of the pressure transducer directly into compartment. thesolid state transducer intracompartmental catheter (STIC) was described in 1984 and measurements were correlated with conventional pressure monitoring systems.93 This device is now commercially available and widely used, although to retain patency of the catheter for continuous monitoring an infusion must be used with its attendant problems. The alternative is intermittent pressure measurements, which is likely to cause significant discomfort to patients and is more labor intensive
WHY TORNIQUET?
do fasciotomy in blood less field to save time and to reduce risk of iatrogenic tissue damage, especially to nerves
deflate immediately after procedure – 5-10 minutes
WHY EXTENSILE?
- limited exposure may not allow for complete decompression
- blind procedure is prone to iatrogenic tissue damage
- post ischemic hyperemia following fasciotomy increases volume of limb further, resulting even muscles to protrude through the incision site - limited incision will not allow that swelling
The anterior compartment contains the extensor muscles of the foot and ankle. Its medial boundary is the lateral (extensor) surface of the tibia, and its lateral boundary is the extensor surface of the fibula and anterior intermuscular septum. The anterior compartment is enclosed by the deep fascia of the leg and all its muscles are supplied by the deep peroneal nerve. The compartment’s artery is the anterior tibial artery
The peroneal compartment is bounded by the anterior intermuscular septum in front, by the posterior intermuscular septum behind, and by the fibula medially. It contains the peroneal muscles which evert the foot. The superficial peroneal nerve supplies all the muscles in the compartment. No artery runs in it; its muscles receive their supply from several branches of the peroneal artery
The superficial flexor compartment contains three muscles: the gastrocnemius, soleus, and plantaris. The compartment is separated from the lateral (peroneal compartment) by the posterior intermuscular septum. It is separated from the deep posterior flexor compartment by a fascial layer
To decompress the anterior and lateral compartments, make a longitudinal incision overlying the anterolateral aspect of the lower leg. A: Begin at the level of the tibial tubercle and extend the incision to end 6 cm above the level of the ankle. B: Incise the fascia overlying the anterior and lateral compartments in the line of the skin incision
To decompress the superficial and deep flexor compartments, make a longitudinal incision overlying the posteromedial aspect of the lower leg. Begin at the level of the tibial tubercle and extend the incision distally, ending 6 cm above the ankle. At right, transverse section showing the fascial compartments. Incising the fascia overlying the anterior, lateral, and superficial flexor compartments is easy. Decompressing the deep flexor compartment may involve lifting the soleus muscle of the intermuscular septum and dividing that septum under direct vision, taking care to avoid the posterior neurovascular bundle
First with fibula excision was introduced …. More extensive muscle debridedment and risk of common peroneal nerve injury
Single incision four-compartment fasciotomy without fibulectomy can be performed through a lateral incision that affords easy access to the anterior and lateral compartments.22 Anterior retraction of the peroneal muscles allows exposure of the posterior intermuscular septum overlying the superficial
posterior compartment. The deep posterior compartment is entered by an incision immediately posterior to the posterolateral
border of the fibulaDouble incision fasciotomy is faster and probably safer than single incision methods because the fascial incisions are allsuperficial Using the single incision method, it can be difficult to visualize the full extent of the deep posterior compartment.Both methods seem to be equally effective at reducing ICP. In the thigh and gluteal regions decompression is simple
and the compartments are easily visualized.
Less common due to volumious space
Nonoperative treatment for TCS is controversial. At minimum, it should be reserved for the awake, interactive patient who can be properly followed up clinically. It should be undertaken in a hospital setting, and the patient, family, and all members of the medical team should have a clear dialogue
Medial approach_ The pubic tubercle and saphenous hiatus are palpated and an incision starting between the 2 and coursing toward the medial epicondyle is made along the course of the saphenous vein
Lateral approach_ A line is drawn from the tip of the greater trochanter proximally to the lateral epicondyle of the femur distally
For patients in whom the diagnosis has been delayed for more than twelve hours (or even 6 hours in the face of high intracompartmental pressures), strong consideration should be given to avoid exposing these damaged tissues to the environment due to increased infection risk
The volar compartment contains three layers
superficial - PT, FCR, PL, FCU
intermediate - FDS
and deep - FDP, FPL, PQ
extensor compartment
- ECRL, ECRB, ECU
- ED, EI, EDM
- APL, EPB, EPL
- all are held in place in the wrist region by the ER, preventing them to bowstring when hand is extended at wrist joint
mobile wad is brachioradialis, ECRB, ECRL
It continues with a curved incision towards the radial side of the mid-forearm and proximally on the anterolateral aspect of the forearm, as in a standard Henry approach.
If needed, the dermato-fasciotomy should cross the anterolateral aspect of the elbow, maintaining coverage of the neurovascular bundle running through the cubital fossa in those cases where the wound is left open. A straight incision across the anterior elbow may result in contracture of the joint
In the mid-forearm, the curved incision with its apex on the anterolateral aspect of the mid-forearm will expose the flexor compartment. Through this part of the incision, the deep volar compartment may be approached between the radial artery and the flexor carpi radialis muscle. The artery is retracted laterally (and not medially as with the standard approach to the midshaft of the radius. The superficial flexor muscle mass is exposed and the overlying fascia released. This includes the finger and wrist flexors, and exposes the median nerve, which should be identified between the deep and superficial flexor muscles and protected, gently retracting it medially with the superficial flexor muscle mass.
The radial artery is retracted laterally with the brachioradialis muscle and superficial radial nerve, to expose and permit division of the fascia over the deep flexor muscles.
Releasing the extensor carpi ulnaris muscle belly from the posterior aspect of the ulna may be sufficient, although there are no data to support this and a clinical decision has to be made during the procedure
Identify each muscle individually to ensure that a complete release is done.
Passively flex the metacarpophalangeal joints, and extend the proximal interphalangeal joints to stretch the muscles, ensuring that all are adequately released
Vacuum wound management devices are often used in this setting and they may reduce the swelling more quickly and potentially allow earlier skin closure with less need for grafting.
In many cases, a complete delayed primary closure of a dermato-fasciotomy wound can be achieved in the pediatric patient.
VACUUM ASSISTED
- How wound is exposed to subatmospheric pressure of about 125 mmHg (50-200) sterile polyurethane sponge is cut to fit with the entire wound surface
-adherent plastic sheet is placed to cover the wound and tubing, which is connected a reservoir and pumb
-edema fluid is removed from extravascular space
benefit - the mechanical tension stimulates proliferation of granulation tissue
if VAC is done, higher proportions of vacuum treated wounds undergo primary closure without needing skin graft
skin grafting
- gives poor coverage and sensation to wound
- cosmetically non appealing
the best way to avoid skin graft is to avoid post fasciotomy edema
Appropriate care should be given to post operative wounds
