

COMPARTMENT SYNDROME

Jessyca Augustia
NIM: 11.2015.067
 Definition
 condition characterised by raised pressure within a closed
space with a potential to cause irreversible damage to the
contents of the closed compartment
 Acute compartment syndrome

 Chronic exertional compartment syndrome

Acute Compartment Syndrome
 pressure within an osseofascial compartment rises
to a level that decreases the perfusion gradient
across tissue capillary beds, leading to cellular
anoxia, muscle ischemia, and death.
Chronic Exertional Compartment Syndrome
 is an exercise-induced neuromuscular condition
that causes pain, swelling and sometimes even
disability in affected muscles of the legs or arms
 can occur in both beginning and seasoned athletes
in sports that involve repetitive movement
 Where does it occur?

Lower Extremity
 Gluteal

 Thigh

 Lower Leg

 Foot

Upper Extremity
 Deltoid

 Arm

 Forearm

 Hand
 Muscle compartments of the forearm.

 The forearm consists of three major compartments:

the volar, dorsal, and mobile wads.
 Compartments of the leg
 Etiology

 Conditions that

1. Reduces the volume of a compartment

2. Increases the content of the compartment

Reduce the Volume
 Cast or Splint

 Circumferential constricting dressing

 Closure of fascia

 Military antishock trousers (MAST)

 3rd degree Burns (circumferential)

 Malfunctioning sequential compression devices (SCDs)

 Tight ski boots

Increase the Content
 Fractures, direct tissue trauma
 Hemorrhage: vascular injury, coagulopathy, anti-coagulation
 Increased capillary permeability after burns
 Infusion or injection (infiltrated line)
 Reperfusion after period of ischemia
 Gunshot wound to thigh
 Drug/alcohol abuse and coma
 Compartment fluid injection
 Crush injuries
 Gastronomies or peroneus muscle tear
 Androgen abuse/muscle hypertrophy
 Ruptured Baker cyst
High risk Injuries causing compartment syndrome
 Fractures of elbow (supracondylar fractures)

 Fractures of forearm bones

 Fractures of proximal third of tibia

 Multiple fractures of the foot and hand

 Crush injuries

 Burns
Pathophysiology
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Pathophysiology
Compartment Pressures Rise

Venous obstruction occurs, causing further pressure

escalation

Low intramuscular arteriolar pressure is exceeded

MUSCLE AND NERVE ISCHEMIA

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Decreased tissue perfusion

tissue death

 Muscle – reversible damage after 4 hours; irreversible after 8 hours

 Nerve damage irreversible after 8 hours

 Episodes of hypotension will therefore increase the extent of irreversible muscle damage

 In tissue damaged by injury, resistance to ischemia is decreased. A pressure of 20mm Hg

below diastolic shown to cause ischemia
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•Rabdomyolysis
Ischaemic fibrotic contracture •Hypovolumia
•Hyperkalamia
Areas of muscle infarction •Increase uric acid
•Metabolic acidosis

Acute renal
Hypovolumia +
failure
myoglobulinaemia

Hyperkalamia Cardiac arrest

 Clinical Manisfestations

6 P’s of compartment syndrome

Parasthesia

Pulselessnes
Pain
s

Paralysis Pressure

Pallor
1.Paresthesia
 Subtle first symptom Compartment Syndrome
 Best elicited by direct stimulation
 Complaints of tingling or burning sensations
 Loss of 2 point discrimination
 Can lead to numbness
2. Pain
 Out of proportion to the injury
 Elicited by passive stretching of the involved compartment
 Described as throbbing or deep – localized or diffuse
 Increases with the elevation of the extremity
 Unrelieved by narcotics
 May not be present if central or peripheral sensory deficits are also
present
 Pain will diminish after pressure-induced ischemia affects the conductivity
of the nerves in the compartment.
3. Pressure
 Involved compartment or limb will feel tense and warm on palpation
 Skin is tight and shiny
 Skin may appear cellulitic
 Direct compartment pressure of 30-40 mmHg as measured by a wick, continuous
infusion, or injection method such as the Stryker monitor – normal
intracompartmental tissue pressure is
 0-10 mmHg.

 Differential pressure of greater than 30 mmHg – diastolic blood pressure minus

compartment pressure – as long as diastolic pressure remains high enough or at
least 30 mmHg, the compartment will be perfuse
4. Pallor
 Late sign
 Pale, grayish or whitish tone to skin
 Prolonged capillary refill (>3 seconds)
 Cool feel to skin upon palpation due to lack of
capillary perfusion
5. Paralysis
 Late sign
 May start as weakness in active movement of
involved or distal joints
 Leads to inability to move joint or digits actively
 No response to direct neural stimulation due to
damage
6. Pulselessness
 Late sign
 Very weak or lack of palpable or Doppler audible
pulse
 Due to lack of arterial perfusion
Other warning signs :
 Fractured blisters: represent areas of necrosis of the epidermis and
separation of the skin layers-body attempts to relieve the pressure in the
compartment.

 elevated temperature due to ischemia/necrosis of tissue and possible

infectious response.

 stretch pain or pain on passive extension or hyperextension of digits (toes

or fingers, depending

on the site)
 Investigation
 Tissue Pressure Measurement

 Lab Studies

Hematology/chemistry laboratory studies – Serum myoglobin and CK

measurements should be obtained to determine the degree of muscle
necrosis.

Serial CK levels may show increases indicative of a

developing CS.
High CK levels should alert to possible rhabdomyolysis.
Complete blood cell count (CBC) and coagulation studies
 elevated WBC (white blood cell count) and ESR (erythrocyte sedimentation
rate) levels -severe inflammatory response

 elevated Serum Potassium due to cell damage

 lowered Serum pH levels due to acidosis

 anemia worsens muscle ischemia

 look for disseminated intravascular coagulation (DIC), which is rare.

 Imaging Studies

 Plain radiographs of the affected extremity are used to determine fracture pattern, soft-
tissue injury, and radiographic clues that may indicate occult fractures.


 MRIs may show increased signal intensity in an entire compartment on T2-weighted, spin-
echo sequences.


 Computed tomography (CT) scanning is especially useful if pelvic or thigh CS is in the

differential diagnosis.

 Lower extremity venous Doppler or arterial ultrasonography (US) is performed as needed to

address possible DVT or arterial occlusion.
 Management
Medical Theraphy

 Place the affected limb(s) at the level of the heart.

 Elevation is contraindicated because it decreases arterial blood flow and narrows

the arteriovenous pressure gradient and thus worsens the ischemia.

 Remove cast, bandages and any dressing.

 Correct hypo perfusion with crystalloid solution and blood products.

 Mannitol may reduce compartment pressures and lessen reperfusion injury

Surgical Theraphy
 emergency fasciotomy

-should be done in less than 6 hours and no later than 12 hours after
onset

-usually left open protected by suitable sterile dressings

-Inspection of the wound after 48 hours may necessitate further

necrotic tissue excision.

-delayed skin closure or skin grafting may become treatment options

 subsequent orthopedic reductionor fracture stabilization and
vascular repair
 Prognosis

 Depends upon the timeliness of diagnosis and

treatment

 Dependent upon etiology and age of patient

 If recognized and treated before my necrosis, >90%

recover function

 May have some loss of muscle power due to the

fasciotomy