COMPARTMENT SYNDROME

•DIAGNOSIS•INVESTIGATION•MANAGEMENT

DIAGNOSIS

• Clinical features Pain – most important. Especially pain out of proportion to the injury (child becoming more and more restless /needing more analgesia)

• Other features like pallor, pulselessness, paralysis, paraesthesia etc appear very late and we should not wait for these things.

• Most reliable signs are pain on passive stretching of the involved compartment, pain on palpation of the involved compartment and sensory deficit in the distribution of any sensory nerve traversing the involved compartment.

• Pressure measurement – Normal compartment pressure is zero.– There is inadequate perfusion and relative

ischemia when this rises to within 10 – 30 mm Hg of diastolic pressure. There is no effective perfusion when it is equal to the diastolic pressure.

Whitesides Technique

slit catheter (Stryker)

• A difference of less than 30 mmHg between tissue pressure and the diastolic pressure indicates need for fasciotomy

MANAGEMENT

What should we do if pressure is raised1.Split the plaster– Compartmental pressure falls by 30% when cast

is split on one side,– by 65% when the cast is spread after splitting. – Splitting the padding reduces it by a further 10% – complete removal of cast by another 15%.– (Total of 85-90% reduction by just taking off the

plaster)

2. Elevate the limb-Improve venous return (good) but-decrease end capillary pressure

3. Circulation chart- for monitoring (interval 15 minutes)

4. Measure compartment pressure-A difference of less than 30 mmHg between tissue pressure and the diastolic pressure indicates need for fasciotomy.

When should fasciotomy be done?

• difference of less than 30 mmHg between tissue pressure and the diastolic pressure indicates need for fasciotomy.

• time interval between trauma and the operation was the main factor in the poor results; avg delay of 23 H due to secondary referral.

• Morbidity from fasciotomy is minimal and should be done as soon as possible.

• If facilities for measuring comparment pressure are not available, clinical assesment is very important

• The limb should be examine at 15 minutes interval.

• If there is no improvement after removal of splint and dressings, fasciotomy should be done (muscle will loss after 4-6 of total ischemia)

How to do fasciotomy• Forearm– Three compartments need to be

decompressed in the forearm –volar (superficial and deep), dorsal and the mobile wad of common extensor origin.

– Henry’s approach for volar aspect of forearm– Thompson’s approach for the dorsal

compartment.

• In the leg there are 4 compartments –the anterior, the lateral (peroneal) superficial and deep posterior.

• 3 techniques are recommended– Fibulectomy, – perifibular fasciotomy – double incision fasciotomy.

• The wound should left open and inspected after 2 days

• KIV for another debridement • If healthy wound can be sutured or SSG or

simply allowed to heal by secondary intention.

Delayed Fasciotomy – is it safe ?

• If delayed more than 12 hours – Not safe according to most papers.

• Why not ?– Converts it into an open injury but with dead

tissue inside.– Does not correct associated nerve or muscle

damage.– Intact skin will act as a protection against infection

and should not be removed.