Principles of Fracture Management - Compartment Syndrome

Question 1

What is Compartment Syndrome?

Answer 1

The pressure within a fascial compartment is abnormally elevated, which cuts off the blood flow to the contents of that compartment.

Question 2

Anatomy of Compartments.

Answer 2

Muscles, nerves and vessels surrounded by fascia - sheet of strong fibrous connective tissue that encases contents of the compartment (not able to stretch or expand).

Question 3

Which fractures are most vulnerable to Compartment Syndrome? (2)

Answer 3

1. Supracondylar Fracture.

2. Tibial Shaft Injury.

Question 4

What is Acute Compartment Syndrome?

Answer 4

Orthopaedic emergency requiring surgery - fasciotomy - to relieve the pressure within the compartment and restore blood flow.

Question 5

Aetiology of Acute Compartment Syndrome (2).

Answer 5

Acute Injury - Bleeding or Oedema associated with the injury increases compartmental pressure :

1. Bone Fracture.
2. Crush Injury.

Question 6

Complications of Acute Compartment Syndrome (2).

Answer 6

1. Tissue Necrosis.

2. Permanent Damage.

Question 7

Clinical Presentation of Acute Compartment Syndrome.

Answer 7

5Ps :

1. Pain.
2. Paraesthesia.
3. Pale.
4. Pressure - High.
5. Paralysis - Late/Worrying Feature.

Question 8

What feature differentiates Acute Compartment Syndrome from Acute Limb Ischaemia?

Answer 8

Pulselessness - is not a feature in Acute Compartment Syndrome.

Question 9

Properties of Pain in Acute Compartment Syndrome.

Answer 9

1. Disproportionate to Underlying Injury.
2. Exacerbated by Passive Stretching of Muscles.
3. Excessive Use of Breakthrough Analgesia.

Question 10

Investigations of Acute Compartment Syndrome (3).

Answer 10

1. Clinical Diagnosis.
2. Needle Manometry - Compartment Pressure (>20 = abnormal; >40 = diagnostic).
3. X-Ray : No Features.

Question 11

Initial Management of Acute Compartment Syndrome (5).

Answer 11

1. Escalate.
2. Remove External Dressing/Bandage.
3. Elevate Leg to Heart Level.
4. Maintain good BP.
5. Emergency Fasciotomy (Definitive - within 6 hours).

Question 12

What is a Fasciotomy?

Answer 12

Surgical operation to cut through fascia down entire length of compartment and release pressure.

Question 13

Post-Fasciotomy Management (5).

Answer 13

1. Explore to identify and debride necrotic muscle tissue.
2. Leave open and cover with dressing.
3. Explore every few days.
4. Gradually close over weeks.
5. Skin Graft if Not Closing.
6. Aggressive IV Fluids - Myoglobinuria + renal failure following fasciotomy.

Question 14

What is Chronic (Exertional) Compartment Syndrome?

Answer 14

Compartmental pressure rises during exertion - restricting blood flow causing symptoms but pressure falls with rest.

Question 15

Clinical Presentation of Chronic Compartment Syndrome.

Answer 15

Similar symptoms isolated to specific location at affected compartment with activity and resolving with rest.

Question 16

Investigation and Management of Chronic Compartment Syndrome (2).

Answer 16

1. Needle Manometry before, during and after exertion.

2. Fasciotomy.