• "Developmental Dysplasia of the Hip"
• "Colles' fracture"
• "Osteomyelitis"
• "Compartment syndrome"
• "Carpal tunnel syndrome"

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COMPARTMENT SYNDROME

Comprehensive Orthopaedic Exam Notes

Sources: Campbell's Operative Orthopaedics 15th Ed (2026), Bailey & Love's Short Practice of Surgery 28th Ed, Miller's Review of Orthopaedics 9th Ed, Current Surgical Therapy 14th Ed, Recent PubMed Reviews (2021-2026)

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1. DEFINITION

"Compartment syndrome is raised pressure in a fascial compartment to a level that compromises tissue perfusion." - Bailey & Love, 28th Ed

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2. CLASSIFICATION

COMPARTMENT SYNDROME
│
├── ACUTE Compartment Syndrome (ACS)
│   ├── Post-traumatic (most common)
│   ├── Post-ischaemia / Reperfusion
│   └── Non-traumatic
│
└── CHRONIC / EXERTIONAL (CECS)
    └── Recurrent exertion-related pressure increase

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3. ANATOMY - COMPARTMENTS

3a. LEG (4 compartments) - MOST COMMON SITE

The anterior and deep posterior compartments are the most commonly involved.

3b. FOREARM (3 compartments)

3c. THIGH (3 compartments)

3d. OTHER SITES

• Foot (9 compartments - most commonly from calcaneus fractures, incidence ~17%)
• Hand
• Buttock/Gluteal
• Arm
• Shoulder
• Lumbar paraspinous muscles

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4. AETIOLOGY / CAUSES

Causes by Mechanism

CAUSES OF COMPARTMENT SYNDROME
│
├── DECREASED COMPARTMENT SIZE (external compression)
│   ├── Tight plaster casts or dressings
│   ├── Circumferential burns (especially 3rd degree)
│   ├── Tight closure of fascial defects
│   └── Pneumatic antishock garments
│
└── INCREASED COMPARTMENT CONTENT (volume increase)
    ├── Fractures ← Most common cause (70%)
    ├── Soft-tissue trauma / contusions (23%)
    ├── Arterial injury / ischaemia-reperfusion
    ├── IV fluid extravasation (IV contrast under pressure)
    ├── Spontaneous haematoma (anticoagulants/bleeding disorders)
    ├── Limb compression during altered consciousness
    └── Burns (oedema)

Key fact for exams: Fractures are the most common cause (70%), with tibial shaft fractures being the single highest-risk fracture type. Compartment syndrome CAN occur with open fractures - do not be falsely reassured.

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5. PATHOPHYSIOLOGY

INITIAL INSULT
(trauma / compression / ischaemia)
        ↓
Increased tissue pressure in closed compartment
        ↓
↓ Capillary perfusion pressure
(perfusion = MAP - compartment pressure)
        ↓
Local tissue hypoxia → Cellular anoxia
        ↓
Histamine release → ↑ Capillary permeability
        ↓
Protein-rich fluid leaks into interstitium → MORE OEDEMA
        ↓
VICIOUS CYCLE: More pressure → More ischaemia
        ↓
Irreversible muscle necrosis (begins at 4-6 hours)
Nerve ischaemia (type C fibres most sensitive first)
        ↓
Rhabdomyolysis → Myoglobinuria → Acute Tubular Necrosis
        ↓
Late: Volkmann's ischaemic contracture (untreated)

• Significant muscle necrosis occurs when intracompartmental pressure (ICP) >30 mmHg sustained for >8 hours
• Higher pressures cause irreversible damage in shorter timeframes
• Exercise alone can increase muscle volume by 20%, raising CECS risk

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6. CLINICAL FEATURES - THE "6 Ps"

Mnemonic: 6Ps (in order of appearance)

Critical exam point: Pain out of proportion + Pain on passive stretch = hallmark early signs. Paralysis, pallor, and pulselessness are LATE signs - if you wait for these, irreversible damage has occurred.

Pulses are PRESENT in compartment syndrome - their absence is a sign of arterial occlusion, which is a different diagnosis. Do not use presence of pulses to exclude compartment syndrome.

Specific Compartment Signs

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7. DIAGNOSIS

7a. Clinical Diagnosis

• Pain out of proportion
• Increasing pain despite adequate analgesia
• Pain on passive stretch of muscles in the compartment
• Tense, woody compartment

7b. Compartment Pressure Measurement

• Diagnostic uncertainty
• Altered level of consciousness (head injury, sedation, intubation)
• Polytrauma victims
• Uncooperative or unreliable patients

7c. Pressure Thresholds for Fasciotomy

AAOS Clinical Practice Guidelines: Fasciotomy when ΔP (diastolic BP - compartment pressure) is ≤ 30 mmHg.

Measure multiple sites near (but not in) the fracture, in all compartments of the affected limb.

CPK elevation and myoglobinuria are late markers of tissue destruction - should NOT be used to establish diagnosis.

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8. ALGORITHM FOR MANAGEMENT

SUSPECTED COMPARTMENT SYNDROME
          │
    ┌─────┴──────────────────────────┐
    ↓                                ↓
Unequivocally                Patient not alert /
positive clinical             Polytrauma /
findings                      Inconclusive findings
    │                                │
    │                    Compartment pressure measurement
    │                         │              │
    │                      > 30 mmHg      < 30 mmHg
    │                         │              │
    │                         │         Continuous monitoring
    │                         │         + serial examination
    │                         │         ↓ (if ΔP ≤ 30 → ↓)
    └─────────────────────────┘
                  │
            FASCIOTOMY
                  │
         ┌────────┴────────┐
    Within 6-8 h         > 12 h
    Best outcomes        ↑ Complications

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9. TREATMENT

9a. Initial / Emergency Measures

1. Remove all constrictive dressings and split casts to the skin - reduces ICP by 50-85%
2. Position limb at level of heart (NOT elevated) - elevation reduces arterial inflow without improving venous drainage, worsening ischaemia
3. Maintain systemic BP (optimise perfusion)
4. High-flow O2
5. Do NOT delay - if clinical diagnosis is clear → immediate fasciotomy

Do NOT elevate the limb above heart level in compartment syndrome - this is a common mistake.

9b. Fasciotomy - Definitive Treatment

LOWER LEG FASCIOTOMY

• Releases all 4 compartments
• Anterolateral incision: 20-25 cm, between fibular shaft and tibial crest
  • Anterior compartment released first
  • Then lateral compartment through same incision
• Posteromedial incision: 20-25 cm, 1-2 cm posterior to medial border of tibia
  • Superficial posterior compartment released
  • Detach soleus from tibia to release deep posterior compartment

• Lateral incision in line with fibula, from fibular head to 3-4 cm proximal to lateral malleolus
• Releases all 4 compartments but technically more demanding
• Risk of injury to superficial peroneal nerve

FOREARM FASCIOTOMY

• Volar: Curved incision from antecubital fossa to palm (Henry's approach) - releases superficial + deep volar
• Dorsal: Straight dorsal incision - releases dorsal compartment
• Carpal tunnel release if hand involved
• Consider mobile wad (BR, ECRL, ECRB) release

THIGH FASCIOTOMY (Tarlow et al.)

• Lateral incision from intertrochanteric line to lateral epicondyle
• Incise iliotibial band
• Release lateral intermuscular septum → releases anterior and posterior compartments
• Medial incision only if medial compartment pressure elevated

9c. Post-Fasciotomy Wound Management

Fasciotomy wound LEFT OPEN
        ↓
Vacuum-Assisted Closure (VAC) device applied
(reduces oedema, promotes granulation)
        ↓
Re-inspect at 48-72 hours
        ↓
Delayed Primary Closure (when swelling subsides) OR
Split-Thickness Skin Graft (if cannot close primarily)

Never attempt early primary closure - this may cause recurrence of compartment syndrome.

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10. CHRONIC EXERTIONAL COMPARTMENT SYNDROME (CECS)

Features

Diagnostic Criteria (Pedowitz Criteria)

Differential Diagnosis of CECS

• Stress fracture
• Nerve entrapment syndrome
• Popliteal artery entrapment syndrome
• Vascular claudication
• Lumbosacral radiculopathy
• Neurogenic claudication
• Myopathy / infection / tumour

Treatment of CECS

CECS TREATMENT
│
├── NONOPERATIVE (1st line)
│   ├── Activity modification / relative rest
│   ├── NSAIDs
│   ├── Physiotherapy (stretching, strengthening)
│   ├── Orthotics
│   ├── Forefoot running technique (↓ ICP, 65-75% success)
│   └── Manual therapy
│
└── OPERATIVE (if non-op fails)
    ├── Fasciotomy of affected compartment(s)
    ├── Anterior fasciotomy: 80-90% success rate
    └── Deep posterior fasciotomy: 50-70% success rate

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11. COMPLICATIONS

If Compartment Syndrome is Missed / Delayed Treatment

Complications of Fasciotomy Itself

• Wound infection
• Haematoma
• Nerve injury (superficial peroneal nerve at risk in single-incision technique) | Hypertrophic / ugly scarring
• Skin graft morbidity
• Inadequate decompression (missed compartments)

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12. SPECIAL SITUATIONS

Reperfusion Compartment Syndrome

• After revascularisation of acutely ischaemic limb (prolonged ischaemia >6 hours)
• Prophylactic fasciotomy recommended at time of revascularisation
• More severe the ischaemia, more likely reperfusion CS to develop
• Monitor CPK; if rhabdomyolysis: aggressive IV fluids targeting urine output >100 mL/hr until CPK <5000 U/L; urine alkalisation with bicarbonate

Compartment Syndrome with Open Fractures

• Do not assume fasciotomy is unnecessary with open fractures
• Skin opening does NOT decompress fascial compartments
• High index of suspicion required

Compartment Syndrome in Tibial Plateau Fractures

• High-energy patterns (Schatzker V/VI) carry high risk
• Monitor closely post-op
• Recent review 2022 (PMID: 34799021) highlights tibial plateau fractures as a high-risk group

Compartment Syndrome After Arthroplasty

• Uncommon but well-described after knee and hip arthroplasty
• Review 2022 (PMID: 34799019) in Orthop Clin North Am

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13. VOLKMANN'S ISCHAEMIC CONTRACTURE

This is the classic end-stage complication of untreated forearm/hand compartment syndrome - very high-yield for exams.

Pathology

Clinical Grading (Seddon's Classification)

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14. QUICK REVISION TABLE - HIGH-YIELD FACTS

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15. RECENT EVIDENCE (2021-2026)

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16. EXAM WRITING TIPS

1. Define → Classify → Anatomy
2. Aetiology → Pathophysiology
3. Clinical features (early vs late) + special clinical tests
4. Diagnosis (clinical + pressure measurement + thresholds)
5. Management (emergency measures → fasciotomy technique → wound care)
6. Complications (of the syndrome and of fasciotomy)
7. Special scenarios (CECS, reperfusion, open fractures)
8. Volkmann's contracture

• "Why do we NOT elevate the limb?" - Elevation decreases arterial inflow without significantly increasing venous outflow
• "Which nerve is most sensitive to compartment ischaemia?" - Type C non-myelinated fibres (sensory)
• "Can compartment syndrome occur with open fractures?" - YES
• "What is the ΔP formula?" - Diastolic BP minus Compartment Pressure ≤ 30 mmHg = fasciotomy
• "What are Pedowitz criteria?" - For CECS diagnosis

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Note on requested textbooks: Turek's Orthopaedics and Tuli's Textbook of Orthopaedics are not currently in the digital library. The notes below are compiled from Campbell's Operative Orthopaedics 15th Ed 2026, Bailey & Love's Short Practice of Surgery 28th Ed, Grainger & Allison's Diagnostic Radiology, Schwartz's Principles of Surgery, and Rockwood & Green's Fractures in Adults 10th Ed 2025, supplemented with classic and recent PubMed literature.

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SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE / SUFE)

Comprehensive Orthopaedic Exam Notes

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1. DEFINITION

Correct anatomical terminology: It is technically the metaphysis (femoral neck) that displaces anterolaterally and superiorly relative to the fixed epiphysis - since the epiphysis is held in the acetabulum. The term "slipped epiphysis" is therefore a misnomer, but universally used.

• Commonest hip disorder of adolescence
• Incidence: ~5 per 100,000 population
• Peak age: 10-16 years, puberty
• Boys more than girls (2:1), though peak occurs earlier in girls (due to earlier puberty)

---

2. AETIOLOGY AND RISK FACTORS

Mechanical / Physiological Factors

GROWTH SPURT
     ↓
Physeal changes during puberty:
• ↑ Obliquity of physis (more vertical → ↑ shear forces)
• Thinning of perichondrial ring
• Widening of physis
• ↓ Neck-shaft angle
• ↓ Size of epiphyseal tubercle
• ↑ Growth hormone → weakens hypertrophic zone of physis
     ↓
Weakened physis subjected to torsional/shear forces
     ↓
SCFE

Risk Factors (Campbell's Box 38.8)

Endocrine rule for exams: If SCFE occurs in an atypical patient (age <10 or >16, underweight, bilateral), always investigate for an endocrine cause (especially hypothyroidism).

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3. PATHOLOGY

• The slip occurs through the hypertrophic zone of the physis (zone of provisional calcification) - same as Salter-Harris Type I fracture
• The epiphysis displaces posteromedially and inferiorly
• Metaphysis (neck) moves anterolaterally and superiorly
• Results in:
  • Increased anteversion lost → retroversion
  • "Cam" type femoroacetabular impingement (FAI) in chronic slips
  • Disruption of blood supply in severe/unstable slips → AVN

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4. CLINICAL FEATURES

Symptoms

Signs

Key exam point: Drehmann's sign - obligatory external rotation of hip on flexion - is pathognomonic of SCFE.

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5. INVESTIGATIONS

X-Rays (Mandatory)

Critical point: Frog-leg lateral is more sensitive than AP. Do NOT accept only an AP view in a child with hip/knee pain.

Key Radiological Signs on AP Pelvis

• A line drawn along the superior border of the femoral neck (Klein's line) normally intersects the lateral part of the femoral epiphysis
• In SCFE, the epiphysis is displaced medially/inferiorly → Klein's line fails to intersect the epiphysis (or intersects less than normal)

• Double density (sclerosis) at the metaphysis on AP view
• Due to overlap of the posteriorly displaced epiphysis with the neck

Southwick Slip Angle (Lateral view)

• Measured on frog-leg lateral view
• Normal neck-shaft angle ~12°
• Mild: <30°, Moderate: 30-60°, Severe: >60°

AP Pelvis showing Klein's line bilaterally

MRI

• Useful for preslip (physeal oedema before visible displacement)
• Also for diagnosis in inconclusive X-rays
• Can diagnose contralateral preslip

CT

• Useful to assess degree of slip and plan osteotomy

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6. CLASSIFICATION

6a. By Duration of Symptoms (Traditional)

Traditional classification is descriptive but has limited prognostic value (Campbell's).

6b. By Stability - Loder Classification (Most Important)

Most widely used and prognostically important classification. An unstable SCFE is a surgical emergency.

Satisfactory results: 96% stable vs 47% unstable (Loder et al.).

6c. By Severity of Slip

6d. Preslip

• Symptomatic physeal weakening without visible displacement
• Widening/irregularity of physis on X-ray
• Physeal oedema on MRI

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7. MANAGEMENT

Algorithm

SCFE CONFIRMED
       │
  ┌────┴────┐
STABLE    UNSTABLE (emergency - cannot walk)
  │              │
  ↓              ↓
In Situ     Urgent surgery within 24 h
Fixation    Gentle repositioning under GA
(1 cannulated  + Capsulotomy to reduce tamponade
screw)         + Fixation with 1-2 cannulated screws
  │
  ↓
MILD SLIP (Stable)      MODERATE/SEVERE SLIP (Stable)
   │                            │
In situ fixation         In situ fixation OR
(90%+ success)           Modified Dunn procedure
                         (controversial - risk of AVN)
                                │
                     If deformity causes FAI after healing:
                         Osteochondroplasty / Osteotomy

7a. In Situ Pinning (Standard Treatment)

1. Patient supine on fracture table
2. Fluoroscopic guidance (C-arm)
3. Percutaneous single cannulated screw (4.5 or 7.3 mm)
4. Entry point on anterior thigh, adjusted for degree of slip
5. Screw placed perpendicular to physis, in center-center position of femoral head
6. Screw tip should be ≥4 mm from subchondral bone (prevents penetration)
7. Capsulotomy for acute/unstable slips (reduces intracapsular tamponade on blood supply)
8. Confirm non-penetration with multiple fluoroscopic views

• Single screw fixation is standard (Aronson & Carlson)
• 2 screws for acute unstable slips
• Screw perpendicular to physis (not to femoral neck axis) - this is important
• Do NOT attempt forceful reduction in stable/chronic slips

7b. Modified Dunn Procedure (Leunig, Slongo & Ganz - Technique 38.22)

• Lateral decubitus position; Gibson approach
• Trochanteric flip osteotomy
• Surgical dislocation of the femoral head (safe dislocation preserving blood supply via MFCA - deep branch)
• Neck osteotomy and realignment of epiphysis
• Fixation with K-wires/screws
• Trochanteric reattachment

7c. Other Surgical Options

The closer the osteotomy is to the deformity (CORA = at the physis), the better the correction but higher the AVN risk. Intertrochanteric osteotomy trades some correction for lower risk.

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8. BILATERAL SCFE

Prophylactic Pinning of Contralateral Hip

• Age: females <10 years; males <12 years
• Endocrine abnormalities
• Unreliable follow-up
• Posterior sloping angle >12 degrees (Fig 38.119)
• Open triradiate cartilage
• Low vitamin D
• Hypothyroidism / Severe obesity / Diabetes mellitus
• History of human growth hormone use

Kocher decision analysis: observation is optimal in most, but prophylactic fixation in high-risk patients or poor follow-up.

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9. COMPLICATIONS

Complications of SCFE Itself

Complications of Surgery

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10. BLOOD SUPPLY OF FEMORAL HEAD (Key for understanding AVN)

Main blood supply to femoral head in adolescent:
→ LATERAL EPIPHYSEAL VESSELS
  (terminal branches of MEDIAL FEMORAL CIRCUMFLEX ARTERY - deep branch)
  
These vessels run:
- Posterior and superior to femoral neck
- Enter epiphysis at the epiphyseal tubercle
- Supply the lateral 2/3 of femoral head

In SCFE:
- Stable slips: vessels stretch but remain intact → low AVN risk
- Unstable slips: vessels avulsed/compressed → high AVN risk (~47%)
- Forced reduction: can further compromise these vessels → DO NOT REDUCE

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11. SCFE AND FAI

• Residual deformity after SCFE → prominent anterior femoral neck (metaphysis) = cam-type FAI
• During flexion and internal rotation: cam lesion impinges on acetabular rim → cartilage damage → early OA
• Management: Osteochondroplasty (after physeal closure) - arthroscopic or open
• Modified Dunn procedure aims to prevent this by anatomical realignment

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12. QUICK REVISION TABLE

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13. EXAM WRITING TIPS

1. Definition + anatomy (what actually slips and why the name is a misnomer)
2. Incidence + epidemiology
3. Aetiology (mechanical + endocrine/predisposing factors)
4. Pathology (which zone of physis, direction of slip)
5. Classification (Duration: acute/chronic/acute-on-chronic; Loder: stable/unstable; Grade: mild/mod/severe)
6. Clinical features (pain at knee - Hilton's law, Drehmann sign, ER deformity)
7. Investigations (AP + frog lateral; Klein's line; Blanch sign; Southwick angle)
8. Treatment (based on Loder classification + severity)
9. Complications (AVN, chondrolysis, FAI, OA)
10. Bilateral SCFE and prophylactic pinning

• "A 12-year-old boy presents with knee pain - what do you do?" → Examine the hip; take AP + frog lateral pelvis
• "What is Drehmann's sign?" → Obligatory ER on hip flexion
• "What is Klein's line?" → Line along superior femoral neck; fails to transect head in SCFE
• "What is the single most important classification?" → Loder (stable vs unstable)
• "What is the AVN risk in unstable SCFE?" → ~47%
• "Why not reduce a chronic stable slip?" → High AVN risk with manipulation; outcomes of in situ fixation are good
• "What is the modified Dunn procedure?" → Surgical dislocation + neck osteotomy + realignment; preserves MFCA blood supply

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Note: Turek's Orthopaedics and Tuli's Textbook of Orthopaedics were not available in the digital library. Classic concepts from these texts are well incorporated in Campbell's and are covered throughout these notes. If you have specific Tuli or Turek content in mind, please let me know and I can address those points from my knowledge base.