Compartment Syndrome

Compartment Syndrome

Q. 1

Indication for surgical compartment release in compartment Syndrome in any compartment is absolute pressure greater than?

 A 15 mm Hg
 B

20 mm Hg

 C 30 mm Hg
 D Varies from compartment to compartment
Q. 1

Indication for surgical compartment release in compartment Syndrome in any compartment is absolute pressure greater than?

 A 15 mm Hg
 B

20 mm Hg

 C 30 mm Hg
 D Varies from compartment to compartment
Ans. C

Explanation:

30 mm Hg REF: With text

“Setting the threshold for fasciotomy at a perfusion pressure of 30 mmHg can be considered safe, but still may lead to overtreatment if used routinely” REF: Evidence-based Orthopedics – Mohit Bhandari Page 634

Different authors consider surgical intervention if: (REF: Tiwari A, Haq A I, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg 2002; 89: 397-412.)

  1. Absolute ICP greater than 30 mmHg
  2. Difference between diastolic pressure and ICP greater than 30 mmHg
  3. Difference between mean arterial pressure and ICP greater than 40 mmHg

“Intracompartmental pressure may be measured by the wick catheter in patients suspected to have compartment syndrome. By such method a pressure of 30 mm Hg or more sustained for 6-8 hours or more is a likely indication for decompressive fasciotomy” REF: Skeletal injury in the child by John Anthony Ogden Page 317

Intracompartmental

pressure

Comments

<15 mm Hg

Normal compartment pressure of lower limbs

>25 mm Hg

Venous drainage from closed myofascial spaces is impaired.

>30 mm Hg

Complete venous collapse

>60 mm Fig

Neuromuscular ischemia

REF: Mastery of vascular and endovascular surgery – Gerald B. Zelenock, Thomas S. Huber, Louis M. Messina Page 507


Q. 2

Which passive movement causes pain in deep posterior compartment syndrome?

 A

Foot abduction

 B

Dorsiflexion of foot

 C

Plantar flexion of foot

 D

Foot adduction

Q. 2

Which passive movement causes pain in deep posterior compartment syndrome?

 A

Foot abduction

 B

Dorsiflexion of foot

 C

Plantar flexion of foot

 D

Foot adduction

Ans. B

Explanation:

 

  • Compartment syndrome (CS) occurs whenever increased tissue pressure in a myofascial compartment compromises blood flow to the muscles and nerves within that compartment, resulting in tissue and nerve damage. The compartments of the lower leg and the volar forearm are particularly prone to developing elevated compartment pressures.
  • Two types of CS have been identified, acute and chronic.

Q. 3

Indication for surgical compartment release in Compartment Syndrome is an absolute pressure greater than?

 A

15 mm Hg

 B

20 mm Hg

 C

30 mm Hg

 D

Varies from compartment to compartment

Q. 3

Indication for surgical compartment release in Compartment Syndrome is an absolute pressure greater than?

 A

15 mm Hg

 B

20 mm Hg

 C

30 mm Hg

 D

Varies from compartment to compartment

Ans. C

Explanation:

Acute compartment syndrome occurs when the tissue pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischemia.

Compartmental pressures higher than 30 mm Hg require surgical intervention.

If such high compartmental pressures are left untreated, within 6-10 hours, muscle infarction, tissue necrosis, and nerve injury occur.


Q. 4

All are relevant in compartment syndrome, EXCEPT:

 A

Fasciotomy

 B

Splitting of tight pop cast

 C

Reexploration

 D

Exercise

Q. 4

All are relevant in compartment syndrome, EXCEPT:

 A

Fasciotomy

 B

Splitting of tight pop cast

 C

Reexploration

 D

Exercise

Ans. D

Explanation:

Exercise may increase intracompartmental pressure and muscle edema, so it is avoided in case of acute compartment syndrome.

Ref: Tachdjian’s Pediatric Orthopedics 3/e, Page 2139-77, 2060; Rockwood and Green’s Fracture in Children 6/e, Page 543-86; Apley’s 8/e, Page 596-99, 563-64; Watson Jones : Fracture and Joint injuries 6/e, Page 591-609.


Q. 5

Which of the following is the commonest cause of anterior compartment syndrome?

 A

Fractures

 B

Gas gangrene

 C

Superficial injury to muscles

 D

Operative trauma

Q. 5

Which of the following is the commonest cause of anterior compartment syndrome?

 A

Fractures

 B

Gas gangrene

 C

Superficial injury to muscles

 D

Operative trauma

Ans. A

Explanation:

Anterior compartment syndrome can be caused by a tibial fracture or a high-velocity blow to the anterior compartment of the leg, resulting in increased pressure in the anterior compartment of the leg.
Because the fascia covering the anterior compartment is unable to expand, pressure continues to build, causing restricted blood flow and eventual necrosis of tissues.
If untreated, anterior compartment syndrome can result in amputation of the limb.

 

 

 

Ref: Morton D.A., Foreman K.B., Albertine K.H. (2011). Chapter 37. Leg. In D.A. Morton, K.B. Foreman, K.H. Albertine (Eds), The Big Picture: Gross Anatomy.

 


Q. 6

Which passive movement causes weakness in deep posterior compartment syndrome?

 A

Foot abduction

 B

Foot inversion

 C

Plantar flexion of foot

 D

Foot adduction

Q. 6

Which passive movement causes weakness in deep posterior compartment syndrome?

 A

Foot abduction

 B

Foot inversion

 C

Plantar flexion of foot

 D

Foot adduction

Ans. B

Explanation:

The deep posterior compartment contains the flexor hallucis longus, flexor digitorum longus, and posterior tibialis muscles, as well as the posterior tibial nerve. In deep posterior compartment syndrome, paresthesias in the plantar aspect of the foot and weakness of toe flexion and foot inversion.


Q. 7

Which passive movement causes pain in deep posterior compartment syndrome?

 A

Foot abduction

 B

Dorsiflexion of foot

 C

Plantar flexion of foot

 D

Foot abduction

Q. 7

Which passive movement causes pain in deep posterior compartment syndrome?

 A

Foot abduction

 B

Dorsiflexion of foot

 C

Plantar flexion of foot

 D

Foot abduction

Ans. B

Explanation:

B i.e. Dorsiflexion of foot 


Q. 8

The most common cause of anterior compartment syndrome is

 A

Fractures

 B

Post ischaemic swelling

 C

Superficial injury to muscles

 D

Operative trauma

Q. 8

The most common cause of anterior compartment syndrome is

 A

Fractures

 B

Post ischaemic swelling

 C

Superficial injury to muscles

 D

Operative trauma

Ans. A

Explanation:

A i.e. Fracture


Q. 9

What is true about compartment syndrome:

 A

Loss of pulses is reliable sign

 B

Pain on passive stretch is reliable sign

 C

Fasciotomy is earliest management

 D

b and c both

Q. 9

What is true about compartment syndrome:

 A

Loss of pulses is reliable sign

 B

Pain on passive stretch is reliable sign

 C

Fasciotomy is earliest management

 D

b and c both

Ans. D

Explanation:

B i.e. Pain on passive stretch is reliable sign > C i.e. Fasciotomy is earliest management


Q. 10

All are relevant in compartment syndrome except:

 A

Fasciotomy

 B

Splitting of tight pop cast

 C

Reexploration

 D

Exercise

Q. 10

All are relevant in compartment syndrome except:

 A

Fasciotomy

 B

Splitting of tight pop cast

 C

Reexploration

 D

Exercise

Ans. D

Explanation:

D i.e. Excercise

Excercise may increase intra compartmental pressure & muscle edema, so it is avoided in cases of acute compartmental syndromeQ.


Q. 11

All are correct regarding compartment syndrome except:

 A

Pulse is a reliable indicator

 B

Pain on passive stretching

 C

Interstitial pressure > capillary pressure

 D

Hyperesthesia

Q. 11

All are correct regarding compartment syndrome except:

 A

Pulse is a reliable indicator

 B

Pain on passive stretching

 C

Interstitial pressure > capillary pressure

 D

Hyperesthesia

Ans. A

Explanation:

A i.e. Pulse is a reliable indicator

  • In compratment syndrome the order of compression of vascular structures with increase of intra compartmental pressure is : capillary compression venous compression arterial compression . That’s why pulselessness is a late feature and it can’t be used as a reliable indicator of compartment syndromeQ. The presence of pulse does not exclude the diagnosis.
  • A split catheter is introduced into compartment & the pressure is measured close to the level of fracture. A differential pressure (Ap) – the difference between diastolic pressure and compartment pressure – of less than 30 mm Hg (4. 00 kPa) is an indication of immediate compartment decompressionQ (fasciotomy).
  • If facilities of measuring compartmental pressure are not available , the limb should be clinically assessed at 15 minutes interval and if there is no improvement with in 2 hours of removing the dressing fasciotomy should be performed. Muscle will be dead after 4- 6 hours of total ischemia – there is no time to loose.

Q. 12

Which of the following causes acute compartment syndrome most frequently

 A

Fractures

 B

Postischemic swelling

 C

Exercise initiated syndrome

 D

Soft tissue injury

Q. 12

Which of the following causes acute compartment syndrome most frequently

 A

Fractures

 B

Postischemic swelling

 C

Exercise initiated syndrome

 D

Soft tissue injury

Ans. A

Explanation:

A i.e. Fractures


Q. 13

Compartment syndrome is treated by

 A

Fasciotomy

 B

Bicarbonate

 C

Chloride rich fluid

 D

Early aggressive fluid

Q. 13

Compartment syndrome is treated by

 A

Fasciotomy

 B

Bicarbonate

 C

Chloride rich fluid

 D

Early aggressive fluid

Ans. A

Explanation:

A i.e. Fasciotomy


Q. 14

A patient develops compartment syndrome (Swelling, pain and numbness) following manipulation & plaster for fracture of both bones of leg. What is the best treatment?

 A

Split the plaster

 B

Infusion of low molecular wt dextran

 C

Elevate the leg after splitting the plaster

 D

Do operative decompression of fascial compartment

Q. 14

A patient develops compartment syndrome (Swelling, pain and numbness) following manipulation & plaster for fracture of both bones of leg. What is the best treatment?

 A

Split the plaster

 B

Infusion of low molecular wt dextran

 C

Elevate the leg after splitting the plaster

 D

Do operative decompression of fascial compartment

Ans. D

Explanation:

D i.e. Do operative decompression of fascial compartment


Q. 15

Characteristic features of the acute compartment syndrome in the lower leg include all of the following except

 A

Acute pain on employing the stretch test

 B

Normal pulses

 C

Normal sensation distally

 D

Venous occlusion

Q. 15

Characteristic features of the acute compartment syndrome in the lower leg include all of the following except

 A

Acute pain on employing the stretch test

 B

Normal pulses

 C

Normal sensation distally

 D

Venous occlusion

Ans. C

Explanation:

C i.e. Normal sensation distally

Compartment Syndrome

Tibial diaphyseal fractures is the most common cause of compartment syndromeQ (overall and in adults); in children the most common cause is fracture supracondylar humerusQ.

In a recent study it has been reported that 69% of compartment syndromes are associated with fracturesQ and 36% of all compartment syndrome are associated with tibial diaphyseal fractureQ.

With the improved results associated with intramedullary nailing of tibial fractures, compartment syndrome has become the commonest serious complication of closed tibial fractures. An open fracture does not protect the patient from compartment syndrome.

It mainly affects young male and is best detected by compartment pressure monitoringQ.

Most of the classical symptoms of compartment syndrome only occur only after there has been irreversible soft tissue damageQ. If the surgeons wait for paresthesia, paralysis, or pulselessness, the patient is highly unlikely to recover full function and it is probable that myonecrosis will already have started. If clinical suspicion is to be used for diagnosis, the diagnosis must be based on increased painQ (disproportionate) and pain on passive muscle stretchQ, as these clinical signs usually occur at an earlier stage. It is extremely difficult to diagnose compartment syndrome clinically, and this problem is exacerbated by the fact that a number of patients will be pain free, unconscious, on ventilators, or anesthetized when compartment syndrome becomes clinically important. When monitoring it is only necessary to record the pressure in the anterior compartment (as it is involved in all cases). The pressure is highest nearer the fracture site, it is there fore important to locate the tip of the catheter near to the fracture site to ensure that the muscle with the highest pressure is monitored. Continuous pressure monitoring is better than single reading.

Surgeons use a single pressure level, usually 30 mm He, or a difference between intra compartment pressure and diastolic blood pressure (diastolic BP – ICP) < 30 mmHgQ as an appropriate criteria to base the decision to undertake fasciotomy.

Subtotal fasciotomy should never be undertaken. All four compartments should be decompressed. Compartment decomression (fasciotomy) should be performed immideatelyQ as delay carries risk of permanent dysfunction.


Q. 16

In posterior compartment syndrome which passive movement causes pain?

 A

Dorsiflexion of foot

 B

Foot inversion

 C

Toe dorsiflexion

 D

Toe planter flexion

Q. 16

In posterior compartment syndrome which passive movement causes pain?

 A

Dorsiflexion of foot

 B

Foot inversion

 C

Toe dorsiflexion

 D

Toe planter flexion

Ans. C

Explanation:

C. i.e. Toe dorsiflexion 

Compartment syndrome is clinically diagnosed by high index of suspicion in any patient with pain out of proportion to injury, who is unresponsive b/O associated head or other injury. Physical findings that warn are pain on passive range of motion of toes causing affected compartmental muscles stretchQ, and tense compartments that are tender on palpation.

So compartment syndrome affecting posterior leg can be earliest diagnosed by passive stretch of toe plantiflexiors that occurs during (passive) toe, dorsiflexion movementQ.


Q. 17

True about intra abdominal compartment syndrome –

 A

Intra abdominal pressure > 15 cm H2O

 B

Pneumoperitoneum can produce it.

 C

↑ Renal blood flow

 D

All

Q. 17

True about intra abdominal compartment syndrome –

 A

Intra abdominal pressure > 15 cm H2O

 B

Pneumoperitoneum can produce it.

 C

↑ Renal blood flow

 D

All

Ans. A

Explanation:

Ans is ‘a’ i.e. Intraabdominal pressure > 15 cm H2O

Abdominal Compartment syndrome

Is caused by acute increase in the intraabdominal pressure, caused by accumulation of large amounts of fluid i.e. blood or edema

It is seen in patients

-who have sustained massive abdominal trauma

had an operation for massive intraabdominal infection or

undergone a complicated prolonged abdominal operation

The Normal intraabdominal pressure (IAP) is nearly 0 cm of H20 and large amounts of fluid accumulation is needed before it begin to rise.

  • When the IAP exceeds 15 cm F120, serious physiological changes begin to occur.
  • The lungs are compressed by the upward displacement of the diaphragm. This causes a decrease in functional residual capacity, increased airway pressure, and ultimately hypoxia. a)

   Cardiac output decreases due to diminished venous return to the heart and increased afterload.

  Both venous return and arterial perfusion of every intraabdominal organ especially kidneys are severely compromised. This leads to oliguria which may progress to anuria.

As IAP exceeds 25 to 30 cm of H2O life threatening hypoxia and anuric renal failure occurs. 

Physiological Consequences of Increased Infra-abdominal Pressure

Decreased

Increased

Cardiac Output

Cardiac rate

Central Venous Return

Pulmonary capillary wedge pressure

Visceral blood flow

Peak inspiratory pressure

Renal blood flow

Central venous pressure

Glomerular filteration

Intrapleural pressure

 

Systemic vascular resistance

Management

  • The diagnosis is made by measuring bladder pressure (through Foley catheter). It represents the intraabdoinal pressure.
  • Abdominal compartment syndrome is a surgical emergency and treatment includes rapid decompression of the elevated intraabdominal pressure by opening the abdominal wound and performing a temporary closure of the abdominal wall with mesh or a plastic bag. Permanent closure is done 5 to 7 days later when the condition resolves.
  • IAP pressures less than 15 mm of 1120 do not require decompression.

Q. 18

True about Abdominal compartment syndrome:

 A

Cardiac Output

 B

Pulmonary capillary wedge pressure

 C

Venous return

 D

a and c

Q. 18

True about Abdominal compartment syndrome:

 A

Cardiac Output

 B

Pulmonary capillary wedge pressure

 C

Venous return

 D

a and c

Ans. D

Explanation:

Ans is A (Cardiac Output), C (Venous return)


Q. 19

Abdominal compartment syndrome is characterized by the following except –

 A

Hypercarbia and respiratory acidosis

 B

Hypoxia due to increased peak inspiratory pressure

 C

Hypotension due to decrease in venous return

 D

Oliguria due to ureter obstruction

Q. 19

Abdominal compartment syndrome is characterized by the following except –

 A

Hypercarbia and respiratory acidosis

 B

Hypoxia due to increased peak inspiratory pressure

 C

Hypotension due to decrease in venous return

 D

Oliguria due to ureter obstruction

Ans. D

Explanation:

Ans. is `d’ i.e., Oliguria due to uretic obstruction 


Q. 20

Most common cause of acute compartment syndrome in children is ‑

 A

Fracture supracondylar humerus

 B

Transphysealhumerus fracture

 C

Fracture radius /ulna

 D

Fracture shaft humerus

Q. 20

Most common cause of acute compartment syndrome in children is ‑

 A

Fracture supracondylar humerus

 B

Transphysealhumerus fracture

 C

Fracture radius /ulna

 D

Fracture shaft humerus

Ans. A

Explanation:

Ans. is ‘a’ i.e., Fracture supracondylar humerus

Compartment syndrome is most commonly caused by extremity fractures :-

  1. Supracondylar fracture of humerus is the most common cause is children.
  2. Crush injuries to forearm are the most common cause in adults.
  3. Other injuries are fracture both bones forearm, elbow dislocation.

Q. 21

Hyperbaric oxygen is not useful in‑

 A

Anemia

 B

Vertigo

 C

Gas gangrene

 D

Compartment Syndrome

Q. 21

Hyperbaric oxygen is not useful in‑

 A

Anemia

 B

Vertigo

 C

Gas gangrene

 D

Compartment Syndrome

Ans. B

Explanation:

Ans. is ‘b’ i.e., Vertigo


Q. 22

First sign of compartment syndrome is ‑

 A

Pain

 B

Tingling

 C

Loss of pulse

 D

Loss of movement

Q. 22

First sign of compartment syndrome is ‑

 A

Pain

 B

Tingling

 C

Loss of pulse

 D

Loss of movement

Ans. A

Explanation:

Ans. is ‘a’ i.e., Pain

Clinical features of compartment syndrome

  • Four signs are reliable in diagnosing a compartment syndrome :-
  1. Paresthesia or hypesthesia in nerves traversing the compartment
  2. Pain with passive stretching of the involved muscles (stretch pain)
  3. Pain with active flexion of the muscles
  4. Tenderness over the compartment
  • Amongst these, stretch pain is the earliest sign of impending compartment syndrome. The ischemic muscles, when stretched, give rise to pain.
  • Passive extension of fingers (streching the fingers) produce pain in flexor compartment of forearm.
  • Other features are Pulselessness, paralysis, Pallor and pain out of proportion to physical findings.
  • Peripheral pulses, are present initially and disappear later. Therefore, pulse is not a reliable indicator for compartment syndrome.


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