By Suvarna Maharaj

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Compartment Syndrome- an overview

• By Suvarna Maharaj

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Intro

• Compartment syndrome is a limb and life
  threatening condition that occurs when perfusion
  pressure falls below tissue pressure in a closed
  anatomical compartment .
• If left untreated -tissue necrosis and sequele
• Ultimately death
• It is found wherever a compartment is present.

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Causes

• Simple cause THE PRESSURE IS TOO HIGH.
• Either decreased compartment size or increased
  fluid content.
• Increased fluid content-
• intensive muscle use
• burns
• intra-arterial injection
• infiltrated infusion
• haemorrhage
• envenomation

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Causes

• Decreased compartment pressure
• Burns
• Casts
• Military aftershock trousers

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Pathophysiology

• This follows the path of ischemic injury. When
  fluid is introduced into a fixed volume or when
  volume decreases, pressure rises.
• In the case of CS, compartments have a relatively
  fixed volume. An introduction of excess fluid or
  extraneous constriction increases pressure and
  decreases tissue perfusion until no O2 is
  available for cellular metabolism.

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Pathophysiology cont.

• Elevated perfusion pressure is the physiological
  response to rising intracompartmental pressure
  (IP). When IP rises, autoregulatory mechanisms
  are overwhelmed and a cascade of injury develops.
• Tissue perfusion pressure is measured by
  subtracting the interstitial fluid pressure from
  the capillary perfusion pressure. When this
  pressure falls below a critical level, injury
  results.

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Pathophysiology cont.

• When intracompartmentalpresssure rises, venous
  pressure rises. When venous pressure exceeds CPP,
  capillaries collapse. Generally, an
  intracompartmental pressure greater than 30mmHg
  requires intervention.
• At this point, blood flow stops, resulting in
  decreased O2 delivery. Hypoxic injury causes
  cells to release vasoactive substances which
  increases endothelial permeability.

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Pathophysiology cont.

• Capillaries allow continued fluid loss which
  increases tissue pressures and advances injury.
• Nerve conduction slows,tissue ph falls due to
  anaerobic metabolism,surrounding tissue suffers
  further damage, and muscle tissue suffers
  necrosis releasing myoglobin.
• The end is loss of the extremity and possibly,
  the loss of life.

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Clinical- History

• Suspect CS whenever significant pain occurs in an
  extremity
• Mechanism of injury- long bone fracture, high
  energy trauma, penetrating injuries, crush
  injuries
• Remember to ask about anticoagulation-increases
  risk of CS

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Signs

• 5 Ps parasthesia, pallor,pulselessness, pain,
  poikilothermia are not diagnostic of CS. Except
  for pain and parasthesia , the other traditional
  signs are not reliable.
• Severe pain at rest or with any movement
  especially passive stretching of the muscles
  should raise suspicion

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Less common sites of CS

• FOOT
• -Classic signs What are they?
• expected with foot fractures and injury so
  tense tissue bulging maybe the most reliable
  sign.
• -associated with CS of deep posterior compartment
  of leg.

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CS of the hand

• Symptoms from compression causes pain, loss of
  sensation and decreased hand function due to
  pressure on blood vessels and the median nerve
  within the wrist compartment .

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CS of the gluteal region

• The large gluteal muscle mass is confined in
  fascia hence area prone to CS. How?
• Signs include pain especially on passive flexion
  at the hip and tense swelling of the buttock.
  Late signs include foot drop with a loss of
  sensation along distribution of sciatic nerve and
  no active movements of the ankle.

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Workup

• LAB STUDIES
• Often normal and not helpful in diagnosing or
  excluding CS
• Definitive diagnosis is compartment pressure
  measurement using a tonometer if available.
• Remember PITFALLS

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Measurement Methods

• Simple needle
• Wick Catheter
• Slit catheter
• Side Port catheter
• Transducer Tipped Catheter

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Technique

• STRYKER TECHNIQUE
• MERCURY MANOMETER

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Technique
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Demonstration

• Go to www.emprocedures.com/compartment

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ED care

• Stabilize the patient
• Ischemic injury is basis for CS. Additional O2
  should be given.
• IV hydration is essential. Hypovolemia worsens
  ischemia.
• Do not elevate the affected limb-decreases
  arterial pressure
• Fasciotomy is definitive treatment so early
  referral is warranted.

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Fasciotomies

• Two Incision Technique
• Used to adequately decompress all four
  compartments
• Medial Incision made longitudinally just
  posterior to tibia
• Lateral incision made posterior to fibula from
  level of head to lat malleolus
• Closure
• Post-op

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Complications

• Permanent nerve damage
• Infection
• Loss of limb
• Death
• Cosmetic deformity from fasciotomy

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References

• Emedicine Compartment Syndrome by Richard Paula
  MD Director of Research, Assistant Professor of
  Emergency Medicine,University of South Florida
• Mutimedia Procedure Manual- Compartment pressure
  Measurement
• Gluteal Compartment Syndrome following Joint
  Arthroplasty Under Epidural Anaesthesia,Journal
  of Orthopaedics Surgery

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References

• April 2007 By Kumar V Saeed, A Panagopoulos, PJ
  Parker
• Wheeless Textbook of Orthopaedics- Compartment
  syndrome of the Foot.
• Acute Compartment Syndrome Update on Diagnosis
  and treatment by TE Whitesides and MM Heckman
  Academy of Orthopaedic Surgery July 1996

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The end

• Thank you