Compartment syndrome

• Raised pressure in osteofascial compartment
• Elevation of pressure prevents tissue capillary perfusion: causes muscle and nerve damage
• Features: severe pain out of proportion to injury aggravate by muscle stretch and parasthesia
• Causes: trauma, reperfusion, burns, exercise
• Complications of missed compartment: muscle necrosis, myoglobinuria, renal failure, infection, amputation, foot drop from peroneal nerve palsy, volkmann's ischaemic contracture

Management

1. History
2. Examination
3. Investigations
   • Classic symptoms need no further investigations
   • Unclear diagnosis: compartment pressures ?30mmHg over diastolic
4. Treatment
   • Double incision fasciotomy
   • Daily dressings of wound
   • Prophylactic antibiotics
   • Re-examine in 24-48hours to debride necrotic tissue and cover wounds

Tibial Compartment fasciotomy

Compartments of the lower leg

Anterior compartment Tibialis anterior Extensor digitorum longus Extensior hallucis longus Lateral compartment Peroneus Longus Peroneus brevis Posterior compartment Tom-Dick-Harry Tibialis posterior Flexor digitorum Flexor hallucus Plantaris Soleus Gastrocnemius

Indication

• Extensive soft tissue injury of lower leg
• Compartment syndrome

Measurement of compartment pressures

1. Prepare / sterilise skin
2. Infiltrate LA
3. Insert catheter into compartment, inject small amount of saline into cannula to fill dead space
4. Fill manometer tubing with saline + connect to catheter + pressure monitor (ensure no bubbles/other dampening influence)

10-30mmHg < diastolic: Impending ischaemia
>30mmHg < diastolic: Impending/established compartment syndrome - Need urgent fasciotomy

Procedure

1. Full length longitudinal anterolateral skin incision 2cm lateral to crest of mid-tibia from level of tibial tuberosity to just proximal to ankle
   • Anterior compartment: Incise fascia covering tibialis anterior + extend proximally/distally
   • Identify and protect superifical peroneal nerve (lies deep to intermuscular septum)
   • Lateral compartment: undermine skin to get to lateral compartment (avoid superficial peroneal nerve)
2. Single longitudinal 1-2cm posterio-medial incision just medial to posteriomedial border of tibia
   • Identify and retract long saphenous vein
   • Incise deep fascia proximally to level of tibial tuberosity and distally to 5cm proximal to medial malleolus
   • Should be anterior to posterior tibial artery to avoid damage to perforating vessels used for later cutaneous flaps

Closure of fasciotomy

1. Wound should be left open + VAC dressing
2. Suture skin 3-5 days later (when swelling subsided) +/- split skin grafts
3. Keep leg elevated

Complications

• Disruption of venous muscle pump
• Poor healing