Acute Compartment Syndrome

This patient developed an acute compartment syndrome following a

close reduction and casting for a tibial shaft fracture.

He underwent an emergency fasciotomy and an external fixator was applied to stabilize the fracture.The wound was left open leaving the fascia and skin open to prevent recurrence of the compartment syndrome

Clean dressing of gelnet has been applied.

Basic Principle
Compartment syndrome is a microcirculation problem resulting from a vicious cycle of swelling and ischemia of muscle confined in a tight fascial compartment. If pressure is not relieved within 4 hours, it may lead to muscle necrosis and irreversible nerve damage

Mechanism:

Compartment syndrome after a high energy trauma to a limb most common in the lower leg or forearm. This condition is most commonly seen in closed diaphyseal fractures such as tibial shaft and forearm fractures treated by closed reduction and cast immobilization or by IM nailing. It can also be associated with crushing injury to a limb. In both situations where the high energy in diaphyseal fractures or crushing injury cause the cell membrane to be leaky resulting in fluid leakage and swelling of the muscle and a rise in intracompartmental pressure confined in a tight fascial envelope. When the compartment pressure becomes sufficiently high the microcirculation is shut down causing muscle ischemia and swelling resulting even more fluid leakage and higher compartment pressure. Intracompartmental pressure that can shut down microcirculation and perfusion of the muscle is often lower than the arterial systolic pressure. It is therefore still possible to have pounding dorsalis pulses even when the microcirculation to the muscle is shut down in a full blown compartment syndrome.

The most common fracture associated with compartment syndromes are closed fracture of the tibial shafts or forearm fractures treated by closed reduction treatment and cast immobilization or by IM nailing. The high energy diaphyseal fractures and closed reduction manipulation caused trauma and subsequent swelling of the muscle leading to increase compartmental pressure due to leaky cell membrance as a result of the trauma. The intracompartmental pressure that will cause shut down of mircrocirculation to the muscle is often lower than the arterial systoic pressure exceed the systolic pressure of the muscle, microcirculation is cut off resulting in ischemia and further increase in intracompartmental pressure. This is a viscious cycle of ischemia and increasing intracompartment pressure. However the arterial systolic pressure is higher than the systolic pressure of the microcirculation of the muscle. So even if the microcirulation to the muscle is shut off resulting in muscle ischemia, you can still feel a pounding arterial pulse. Like in the case of a full blown comapartment syndrome of the anterior lateral compartment of the leg, the dorsalis pedis may pabably be normal.

In tibial shaft fractures that has undergone closed reduction or IM nailing the fascia are still intact and thus at at risk for developing compartment syndrome. Ironically in fractures treated by open reduction and internal fixation or in fracture with grade III open fractures the fascia is disrupted and thus less prone to develop compartment syndrome.

Compartment syndrome can also result from ischemia and swelling of the forearm muscle when the elbow is immobilized in acute flexion after closed reduction and pinning of a supracondylar fracture.

Presentation:

Common fractures associated with compartment syndrome are:

Midshaft fractures of tibia treated with closed reduction or IM nailing
Midshaft fractures of both bones of the forearm treated with closed reduction
Closed reduction of supracondylar fracture with percutanous pinning and immobilized in acute flexion thus kinking the brachial artery leading to ischemia of the muscles of the forearm.

"Diagnosis can be make across the room"

Patients appear in to severe pain out of proportion to a reduced fracture stabilised with cast or IM nailing.

Additional optional reading material

Trauma either a fracture or crushing injury

Compartment syndrome is a microcirculation problem where the microcirculation to the muscle is impaired due to increase

ANTERIOR COMPARTMENT: contains tibialis anterior , extensor hallucis longus, extensor digitorum,anterior tibial artery, and vein, deep peroneal nerve. (Can be caused by tightness in the gastrocs/soleus)

SUPERFICIAL POSTERIOR COMPARTMENT: gastrocs and soleus

DEEP POSTERIOR COMPARTMENT: tibialis posterior, flexor digitorum longus, flexor hallucis longus, posterior tibial artery, vein, and nerve, peroneal artery and vein

LATERAL COMPARTMENT: peroneus longus, brevis

* (divided by dense, inelastic fascia)

* Any of the compartments may be affected, but anterior compartment is more prone ( about 45%)

*Â Deep posterior compartment syndrome is common as well.

Pain level can be asses by The SOCRATES mnemonic is used to structure a patient's pain history by asking about the site, onset, character, radiation, associations, timing, exacerbating/relieving factors, and severity of the pain.

Student said.

Stryker needle

The "Finger Test" is used, where an incision is made 2cm into the palpable tense compartment. If there is the presence of "soapy dishwater", pale pink/grey and soft muscle which does not contract on stimulation,and fascia that is easily torn, it is likely Compartment Syndrome.

Student answer:
Assess pain level (SOCRATES)

Cause

Trauma either a fracture or crushing injury

Compartment syndrome is a microcirculation problem where the microcirculation to the muscle is impaired due to increase

SUPERFICIAL POSTERIOR COMPARTMENT: gastrocs and soleus

DEEP POSTERIOR COMPARTMENT: tibialis posterior, flexor digitorum longus, flexor hallucis longus, posterior tibial artery, vein, and nerve, peroneal artery and vein

LATERAL COMPARTMENT: peroneus longus, brevis

* (divided by dense, inelastic fascia)

* Any of the compartments may be affected, but anterior compartment is more prone ( about 45%)

*Â Deep posterior compartment syndrome is common as well.

Student said.

Stryker needle

A) What is compartment syndrome? (3 marks)

1) Elevated tissue pressure within a closed fascial space

2) Reduces tissue perfusion -ischemia

3) Results in cell death -necrosis

B) What is the earliest clinical feature suggestive of the development of compartment syndrome? (2 marks)

1) Pain out of proportion

2) Pain on passive stretching of affected limb

(Any 1, 2 marks)

C) Outline your immediate management and definitive management for a patient with compartment syndrome. (5 marks)

1) Immediate management

2) Remove the dressing and backslab (2 marks)

3) Inform senior/ Alert OT and anaesthesia (1 mark)

4) Definitive management

5) Emergency fasciotomy (2 marks)

Acute Compartment Syndrome

Basic PrincipleCompartment syndrome is a microcirculation problem resulting from a vicious cycle of swelling and ischemia of muscle confined in a tight fascial compartment. If pressure is not relieved within 4 hours, it may lead to muscle necrosis and irreversible nerve damage