Compartment Syndrome and Fasciotomy Incisions
These diagrams and illustrations have been designed to help you learn, memorise and recall key information.
IMPORTANT QUESTIONS TO CONSIDER …
When should one perform fasciotomies?
In a conscious patient, this is a clinical decision.
In an unconscious patient pressure monitoring may be helpful.
Pressure criteria: - >30mmHg or within 30mmHg of diastolic pressure.
Remember, compartment pressures can be misleading.
Prayson 2006: - 95% tibial fractures with no clinical indication of compartment syndrome had pressures of >30mmHg!
DEFINITION
Vascular compromise and tissue necrosis within a fascial compartment ...
... resulting from a sustained rise in the intra-compartmental pressure.
CAUSES
Fracture (most common causes) - eg supracondylar fractures in the upper limb.
Crush injury / Lying on a limb for a prolonged period / Burns / Tight cast / Snake bites
PRESENTATION
Severe, disproportionate pain that is persistent, progressive & unrelieved by immobilization.
(The pain is classically worsened by passive stretch of the muscles within the compartment).
Paraesthesia in the distribution of sensory nerves passing through the compartment.
Even with severe ischaemia, the colour and temperature of the distal limb can be normal.
Distal pulses are rarely obliterated but muscle and nerve circulation will be minimal.
Absent pulses should alert one to the possibility of a vascular injury.
DIAGNOSIS
The diagnosis is mainly a clinical one based on muscle and nerve ischaemia.
Intra-compartmental pressures can be measured.
STRYKER needle or WICKS catheter can be used (or an arterial line setup).
Zero the pressure at the level where he needle is placed prior to entering the compartment.
However, not everybody is in favour of measuring the compartmental pressures.
Normal pressure = 0-8mmHg
Compartment syndrome is diagnosed by a pressure within 30mmHg of the diastolic.
It is important to repeatedly reassess the limb (esp following revascularisation of a limb)
- muscle swelling may not develop for several hours.
MANAGEMENT
Delay leads to devastating consequences.
Muscle can tolerate 4hrs of warm ischaemia and certainly no more than 6hrs.
Every effort should be made to achieve an accurate diagnosis.
(Inappropriate fasciotomy can lead to significant morbidity).
FASCIOTOMY
Four compartment decompression.
Fasciotomies need to be long (eg > 16cm).
All non-viable muscle is excised.
Medial incision
- does not compromise the availability of local fasciocutaneous flaps.
- can be used to extend pre-existing traumatic lacerations
- can enables access for debridement
- provides an approach to the post. tibial vessels as recipients for free flaps.
If muscles appears pale, tense and avascular, epimysiotomy can be performed.
This involves stripping the covering from the muscle (it is generally not required).
Fasciotomies are closed (directly or with SSG) once the swelling has reduced.
Late diagnosis of compartment syndrome (this presents a management dilemma).
Once the muscle is no longer viable, compartment release will predispose to infection.
In addition, release of the compartment can lead to “ischaemia-reperfusion”.
Note that this can be lethal.
Compartment release may therefore lead to compartmentectomy and amputation.
UNTREATED COMPARTMENT SYNDROME
If untreated muscle necrosis can occur within 2 hours.
It is important to be aware that even if muscle survives it may function poorly!
There is therefore great urgency to decompress the compartments.
Untreated compartment syndrome leads to Volkmanns Ischaemic Contracture.
