Effects of Raised Tissue Pressure on Muscle
Effects of Raised Tissue Pressure on Nerve
Effects of Raised Tissue Pressure on Bone
Compartment Pressure Monitoring
Threshold for Decompression
Surgical and Applied Anatomy
Author’s Preferred Method of Management
Early diagnosis of acute compartment syndrome is essential, and it is important to be aware of the patients at risk of developing acute compartment syndrome. Good clinical examination techniques in the alert patient will help to identify the compartments at risk. Compartment monitoring should be used in all “at risk” patients as defined in Table 29-3. In practice this means that all tibial fractures should be monitored, but if resources to do so are limited, then younger patients should be selected for monitoring. The anterior compartment should be monitored, but in rare cases where symptoms are present that cannot be explained by the tissue pressures in the anterior compartment, the posterior compartment should also be monitored.
Fasciotomy is performed on the basis of a persistent differential pressure of less than 30 mm Hg (Fig. 29-15). If the ΔP is less than 30 mm Hg but the tissue pressure is dropping, as can happen for instance for a short time after tibial nailing, then the pressure may be observed for a short period in anticipation of the ΔP rising. On the other hand, if the ΔP remains less than 30 mm Hg or is reducing, then immediate fasciotomy is indicated. Delay and complications are minimized by making the decision to perform a fasciotomy primarily on the level of ΔP, with clinical symptoms and signs being used as an adjunct to diagnosis.
I prefer four-compartment fasciotomy in the leg because it is simpler and gives an excellent view of all compartments. If any muscle necrosis is present this should be thoroughly debrided. At this stage if a fracture is present, it should be stabilized if this has not been done previously. Suction dressings if available should then be applied. A “re-look” procedure should be performed at 48 hours after fasciotomy with further debridement if necessary. If the wound is healthy closure should be undertaken at this stage with either direct closure or split skin grafting. I do not use gradual closure techniques because of the risk of wound edge necrosis and prolonged times to coverage. There is no indication to prolong closure beyond 48 hours unless there is residual muscle necrosis.