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Compartment Syndrome Booklet Approval Date Activity: Compartment Syndrome Booklet Approval Date: 3/1/2018 Termination Date: 2/29/2021 Target Audience: Orthopaedic surgery, ER, primary care Planners/ Authors Nabil Ebraheim, MD Course Director, Author, Planner Professor& Chairman Department of Orthopaedic Surgery The University of Toledo Johnathan Cooper Course Coordinator, Planner Research Assistant Department of Orthopaedics The University of Toledo Saaid Siddiqui, MD Document Author, Planner Research Associate Department of Orthopaedic Surgery University of Toledo Disclosures No Planner/Author/Co-Author has any financial interest or other relationship with any manufacturer of commercial product or service to disclose. Activity Objective: After reviewing the course materials, participants will be able to: Review cross section/anatomy of the extremities Describe the pathophysiology of compartment syndrome Diagnose patients presenting with compartment syndrome Discuss management of compartment syndrome and chronic compartment syndrome Accreditation Statement The University of Toledo is accredited by the ACCME to provide continuing medical education for physicians. The University of Toledo designates this educational activity for a maximum of 6 AMA PRA Category 1 Credit(s).TM Physicians should claim only credit commensurate with the extent of their participation in the activity. Physicians requiring CME Read the material Complete the test (must obtain a 70% 22/30) Mail completed test and $10 payment (instructions on last page of test) to: The University of Toledo Center for Continuing Medical Education 3000 Arlington Ave, MS 1092 Toledo, OH 43614 Credit will be awarded to your credit transcript via the UT CME site: cme.utoledo.edu To login Username: lastnamefirstname (no commas, no caps, no spaces) Password: set as your zip code used during your registration (Unless you are already in their system, then use your set password) If you have problems with the content and or questions, please contact: Nabil Ebraheim, MD [email protected] 419-383-4020 Compartment Syndrome Booklet The University of Toledo Orthopaedic Center Editor: Nabil A. Ebraheim, MD Johnathan Cooper Saaid Siddiqui, MD 4 Definition Compartment syndrome is a condition in which increased pressure (from any source) within a closed space compromises the micro-circulation, and reduces perfusion to the tissue contained within the space. Sites Skeletal muscles are grouped in compartments that are enclosed by relatively non- compliant, fascial boundaries which define a limited space (and hence increase risk for compartment syndrome) in each of the following (Fig. 1). Figure 1: Body Sites for Compartment Syndrome. Compartment syndrome can affect any age group and can occur in multiple sites as seen in Figure 1. The most common site is the lower leg. 5 Etiology Figure 2: Acute Compartment Syndrome Etiology. The increased pressure in the compartment may result from any of the etiologies shown in Figure 2. Fractures and Injuries Among the cases with acute compartment syndrome, tibial fracture was the most common. Some of the common fractures associated with compartment syndrome are: o Tibial fractures o Calcaneal fractures o Medial plateau fractures o Severe and complex tibial fractures o Medial knee fracture/dislocations 6 o Forearm fractures o Distal Radius fractures In the pediatric population, tibial tubercle fracture, both radius and ulna fracture, floating elbow injury, and supracondylar humerus fractures are the most common etiologies. Small children may not be able to verbalize their symptoms and increased analgesic requirement, agitation and anxiety are common symptoms. Presence of these findings (Analgesic, Agitation, and Anxiety) in a child should alert the clinician to the possibility of impending compartment syndrome. Soft Tissue Injury Soft tissue injuries are the second leading cause of compartment syndrome. It may result from major crushing trauma in crush syndrome, or minor blunt trauma over the anterior compartment of the leg or volar aspect of the forearm. Exercise Acute Exertional Compartment Syndrome: Exists when intra-compartmental pressure is elevated to a level and duration such that immediate decompression is necessary to prevent muscle necrosis. This usually occurs when an individual participates in a strenuous activity above his or her normal level of training. Vascular Injury/Hemorrhages Vascular injuries may cause blood to accumulate in the compartment, thereby raising the ICP (Intra Compartmental Pressure). Also, smaller blood leaks may over time evolve into a hematoma which may occlude blood flow thereby increasing the ICP as well. Decreased Compartment Size There are three causes of decreased compartment size: 1. Constrictive dressing and casts: A tight cast lowers compliance, and thus restricts the expansion of the tissue. It can elevate the pressure to ischemic levels in the compartment. 2. Thermal injuries and frostbite: Circumferential third degree burn can cause compartment syndrome due to inelastic scarring and/or edema formation. 7 3. Tight closure of fascial defects (muscle hernia) can cause ischemic complications. The physician should not close such defects. Other Causes Other causes of compartment syndrome include gunshot/stab wounds, arterial lines/IV, intraosseous IV (for infants), temporary ischemia, prolonged limb compression (drug overdose and general anesthesia), intramedullary nailing, pneumatic anti-shock garments (PASG), fluid infusion, osteotomy, snake bite, leukemic infiltration, acute hematogenous osteomyelitis, burns and electrical injuries. Risk Factors Risk factors for the development of acute compartment syndrome include: young age male tibial fracture high-energy forearm fracture high energy femoral fracture bleeding diathesis/anticoagulant chronic exertional compartment syndrome 8 Pathophysiology A variety of conditions may initiate a sequence of events that produce compartment syndrome. The resting compartmental pressure is 0-10 mmHg. An increase of that pressure to 30 mmHg (or within 30 mmHg of diastolic blood pressure) will lead to impending compartment syndrome. If the elevated pressure is not relieved within 6-8 hours, irreversible damage to the contents of the compartments could occur. Initiating Event | Edema-Hemorrhage-Accumulation | Elevated Compartment Pressure | Venous Obstruction | Further Elevation of Compartment Pressure | Arteriolar Pressure Exceeded | Loss of Capillary Exchange | Muscle Ischemia/Infarction Nerve Damage ↓ Irreversible Damage to Contents of the Compartment (muscles and nerves) 9 Muscle Changes 1 Within The first 3‐4 3 hours of compartment syndrome, muscular After 8 hours of changes are still established reversible compartment syndrome, irreversible changes have occurred 2 to the muscles After 6 hours, there is clear muscle damage. 10 Nerve Changes 1 Within the first 2 hours, there is a loss of nerve conduction 3 After 8 hours, there is total axonotomesis and 2 secondary scar. If After 4 hours, neuroproxia compartment syndrome develops. The nerves survive, progresses to this stage, but no longer transmit irreversible changes occur impulses. Nerve changes are to the nerves. still reversible 11 Anatomy The most common anatomical sites for acute compartment syndrome are as follows: leg, forearm, foot, hand, and thigh 1 is most common – 5 is least common Fig. 3: The most common anatomical sites for developing compartment syndrome. 12 I. Anatomy of Leg The leg is the most common site in the body to develop compartment syndrome. There are four well defined compartments in the leg (Fig 4). The anterior compartment is the most likely leg compartment to develop compartment syndrome. The deep posterior compartment is the most commonly missed compartment in diagnosis of compartment syndrome of the lower leg. Figure 4: Compartments in leg. The foot is innervated with four different nerves (Fig. 5 & Fig. 6). Each of the four nerves are located in a different compartment, therefore, clinical examination of the foot alone can alert the clinician to the involved compartment. The toe-web space is the most common site involved since it is innervated by the deep peroneal nerve, which is located in the anterior compartment. Figure 5: Innervation of the dorsal aspect of the foot. 13 Figure 6: Innervation of the plantar aspect of the foot. (posterior tibial nerve which is located in the deep posterior compartment). Compartments of the Leg 1. Anterior compartment (Fig.4) (Sensation to first web space) a. Muscles: Dorsiflexors of the foot b. Nerves: Deep peroneal nerve 2. Lateral Compartment (Fig.4) (Sensation to dorsum of the foot) a. Muscles: Peroneal muscles b. Nerve: Superficial peroneal nerve 3. Superficial Posterior Compartment (Fig.4) (sensation to lateral aspect of the foot) a. Muscles: Gastrocnemius, Soleus b. Nerves: Sural nerve 4. Deep Posterior Compartment (Fig.4) (Sensation to the plantar aspect of the foot via multiple branches) a. Muscles: Toe flexors, Tibialis posterior 14 b. Nerves: Posterior tibial Nerve II. Anatomy of Forearm Figure 7: Transverse section through mid-forearm with fascial compartments shown. Compartments of the Forearm The forearm is comprised of four compartments: Superficial Volar Compartment, Deep Volar Compartment, Henry’s mobile Wad and the Dorsal Compartment (Fig 7). 1. Superficial Volar Compartment a. Muscles: PT, FCR, PL, FCU, FDS b. Nerves: Median and Ulnar nerve 2. Deep Volar Compartment a. Muscles: FDL, FPL, PQ b. Nerves: Anterior interosseous Nerve 3. Henry’s mobile wad a. Muscles:
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