Compartment Syndrome

Scenario

You are called to A+E to assess a 32 year old male who fell from a motorcycle at speed. He has a closed midshaft tibial fracture.

I would approach this patient according to ATLS principles. I would stabilise the C-spine and assess the patient’s airway, breathing, circulation and disability in turn. Following investigation/treatment of life threatening injuries I would complete a secondary survey.

Regarding the limb in question I would perform a full neurovascular assessment distal to the injury. In addition, I would ensure that the injury is closed.

I would tend place the patient into an above knee back slab and perform post application of Plaster of Paris X-Rays. In addition, I would ensure the patient is prepared for surgery with CXR, Trauma bloods and MRSA/COVID swabs.

The patient undergoes a tibial intramedullary nail procedure the next day.

I would immediately assess the patient. My main worry would be a compartment syndrome. I would therefore review the patient’s notes and drug chart and take a history from and examine the patient.

I would remove the dressings down to the skin and examine the neurovascular status of the limb. Furthermore, I would assess for tenseness in the compartments and pain on passive stetch.

Clinical

Cardinal features include: Pain out of proportion to injury often refractory to strong analgesia, tense compartments on palpation and pain on passive stretch of the affective compartment.

 

If the diagnosis is in question/unconscious patient

Compartment pressure monitoring can be undertaken. (I have used the stryker system a saline filled syringe is utilised and injected into the compartment).

  • Delta P <30mmHg (difference between diastolic and compartment pressure) McQueen 1996
  • Absolute value >40mmHg

Compartments of the leg

  • Anterior – 1/3rd down tibia 1cm lateral to anterior crest of tibia, Insert 1-3cm deep
  • Lateral – 1/3rd down tibia, over fibula 1cm deep
  • Deep Posterior – 1/3rd down tibia Medial border of tibia towards posterior fibula
  • Superficial posterior – 1/3rd down tibia, medial border 3cm medial to this.

 

Forearm

  • Volar – flex against resistance. Medial to palmaris longus 1/3rd down the arm
  • Dorsal – 1/3rd down the forearm. 1cm off ulnar to radius.

I would manage this patient according to BOAST guidelines. I would inform the consultant on call, anaesthetic team on call, plastics and theatre co-Ordinator. I would mark and consent the patient for a fasciotomy which should occur within 1 hour.

In an appropriately marked and consented patient.

Patient would be given a GA, Supine on the table, Abx on induction.

Clean and prep

 

A 2 incision approach is utilised.

  • To decompress the anterior and lateral compartment an incision starting 2cm lateral to the anterior crest of the tibia is made down the entirety of the leg.
  • To decompress the superficial and deep posterior compartment a second incision is made starting 2cm posteriomedial to the medial crest of the tibia. I would take care to ensure that the deep posterior compartment is released. Ensuring that I run mayo scissors under the soleus bridge.

 

During the medial incision I would take care of the perforators which lie 5cm, 10cm and 15cm superior to the medial malleolus.

Debridement of any necrotic/muscle/tissue would be performed.

 

I would apply a VAC dressing over the incision.

I would perform a relook in 48 hours

Primary wound closure 5-7 days.

It occurs when the intra-compartmental pressure exceeds capillary pressure. Thereby leading to decreased end tissue perfusion.

  • Trauma/fracture
  • Haematoma
  • Iatrogenic – Casts, tight circumferential dressings, extravasation of intravenous injection
  • Reperfusion injury
  • Crush injury
  • Burns