Compartment Syndrome



Circulation of tissues within a closed osteofascial space are compromised by increased pressure within that space


Most common 

- anterior leg compartment

- flexor compartment forearm

- deep posterior leg compartment




Prerequisite is volume restricting envelope 

- fascia & skin


- dressings


1.  Increased contents


Bleeding / edema 

- fracture

- osteotomies 

- crush injuries

- post - ischaemic swelling


2.  Decreased size


Tight casts & dressings

Tight closure of fascial defects

Fracture reduction 




Increased local tissue pressure increases pressure within intracompartmental veins

- local AV gradient is reduced

- causes decreased local perfusion secondary to Starling Forces


Metabolic tissues demands not met

- loss of tissue function & viability

- distal pulses remain as ICP < SBP 

- digit capillary refill remains as venous return extracompartmental 




1. Pain

- most important sign

- much great than expected 

- masked by coma / neural injury 

- unrelieved by opiates


2. Paraesthesia

- often early

- pins & needles or decreased sensation to light touch

- distribution important

- nerve of that compartment will be affected




3. Palpation

- swollen, tense compartment


4. Passive Stretch

- pain on passive stretch 

- subjective

- complicated by underlying trauma


5. Paresis

- may be due to proximal nerve injury or guarding 2° to pain


6. Pulses

- pulse & capillary refill are normally present




Clinical Diagnosis


Tense compartment with pain +++

Pain on passive stretch


Intramuscular Pressure Measurement


Pressure Measurement




1. Unresponsive 

- head injury

- ventilated

2. Uncooperative 

- children, drug abusers

3. Underlying peripheral nerve deficit 

- tibial fracture with CPN nerve deficit




1. Needle - Manometer Method (Whitesides)

- 18G needle is connected via a 3 way stop cock to an air filled 20 ml syringe

- air filled tubing which is connected to a Hg Manometer 

- a small amount of saline sits in tube connected to needle 

- compression of the syringe raises the pressure till saline flows into the compartment

- this is indicated by the meniscus moving


2.  Arterial Pressure Transducer

- i.e. devices used in ICU to measure arterial blood pressure and CVP

- no need to inject fluid

- pressure in saline tube equalizes with compartment

- connect to Wick or Slit catheter

- slits have many longitudinal slits to equalize pressure in tube with compartment


3.  Stryker Device 

- Variation on 2




Matsen > 45 mmHg

Mubarek & Rorabeck > 30 mmHg

Whitesides - within 30mmHg of DBP






Remove all tight dressings

- splitting POP decreases pressure by 30%

- bivalving & cutting padding reduces pressure by another 55%

- elevate limb 


Avoid hypotension 


Ream without tourniquet


Early fasciotomy 


Compartment Release


Full-length skin incision

Complete fasciotomy of all compartments

Assessment of muscle (colour / consistancy / contraction / bleeding)

Debridement dead muscle

Delayed DPC / graft 


2 Incision Technique Leg


Anterolateral compartments

- incision halfway between crest of tibia & fibula

- identify and protect SPN

- expose lateral intermuscular septum (transverse cut)

- release Anterior & Lateral compartments


Posterior compartments

- incision 2 cm posterior to posterior margin of tibia

- identify and protect saphenous vein / nerve anteriorly

- identify septum between superficial & deep compartments

- release fascia over Gastro-Soleus (superficial posterior compartment)

- release deep posterior compartment which is located behind the tibia / FDL


Perifibular Approach / Single incision Technique


Lateral incision beginning just posterior to fibula

- expose & protect CPN

- posteriorly release superficial posterior compartment

- release FHL (deep posterior compartment

- anteriorly expose and release anterolateral compartments after identifying SPN


Compartment Release Forearm


4 interconnected compartments

- volar superficial

- volar deep (FDP / FPL / pronator quadratus)

- mobile wad (BR, ECRL, ECRB)

- extensor



- incision from medial elbow to carpal tunnel

- must release lacertus fibrosis and carpal tunnel

- divide fascia

- this will release superficial flexor muscles

- ensure release mobile wad

- ensure release FDP



- often volar release wil decompress dorsal compartment

- usually ulnar sided incision

- proximal over muscle belly

- distally is mostly tendons


Compartment Release Hand


Two dorsal incisions

- over MT 2 and MT 4

- release interossei compartments


Carpal tunnel incision

- release thenar / hypothenar / adductor

- release carpal tunnel


Compartment Release Foot


2 dorsal incisions

- over MT 2 and MT 4

- release 4 interossei compartments


Medial incision

- release medial / central and lateral compartments




Volkmann's contracture

- ischaemic muscles fibrose & contract

- causes deformity & stiffness

- nerves damaged with variable numbness



Upper limb fasciotomyForearm Fasciotomy Closure


1.  Antebrachial Compartment Syndrome




Supracondylar fracture of humerus

Both bone forearm fractures




Tense compartments

Pain +++

Passive extension of the digits or wrist increases pain

Paresthesias in median nerve distribution


Forearm Fasciotomy 


Decompression extending from elbow to wrist


Compartments (3)

- mobile wad

- volar

- dorsal



- medial arm

- across elbow

- continue as Henry approach into forearm

- can continue into palm as CTD incision



- lacertus fibrosus  (releases median nerve at elbow)

- fascia of forearm (releases superficial volar)

- deep fascial compartments (FCU / FDP / FPL)

- mobile wad


Remeasure dorsal compartment

- often decompression of volar compartment will reduce dorsal pressures




Volkmann's ischemic contracture

- result of delayed diagnosis

- severe muscle fibrosis & neuropathy 

- clawing of fingers


Muscles most commonly affected





- BR to FPL



Compartment Syndrome of Hand




Iatrogenic injuries

- arterial line or infiltration of IV medications

Crushing trauma

IV drug abuse

High pressure injections

- i.e. paint guns




Hand compartment syndromes lack abnormalities in sensory nerves

- no nerves are found within compartment

- non specific aching of the hand


Increased pain, loss of digital motion, continued swelling 

- tight swollen hand in a intrinsic minus position

- MP extension and PIP flexion

- intrinsic tightness (increased PIPJ motion with MCPJ flexion v extension)


Pressure measurement 


Should have a lower threshold than in leg compartments 

- pressures greater than 15-20 mmHg is a relative indication for release




10 separate osteofascial compartments 

- dorsal interossei (4) 

- palmar interossei (3) 

- adductor pollicis (1)

- thenar and hypothenar  (2)





- release thenar / hypothenar / adductor pollicis

- 2 x dorsal incisions over MC 2 and 4