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Compartment syndrome

Description

Compartment syndrome is a limb-threatening condition caused by swelling within the myofacial compartments of the limb. It most commonly occurs in the leg or forearm secondary to trauma and leads to decreased tissue perfusion below basal tissue requirements. 

Structure and function

The leg and forearm both have four compartments encircled by inflexible facia. Compartment syndrome is possible in any or all of the compartments. The anterior and deep posterior compartments of the leg are the most common sites for compartment syndrome.

The anterior compartment of the leg contains tibialis anterior, extensor hallucis longus, extensor digitorum longus. It also contains the anterior tibial artery and the deep peroneal nerve. Signs of acute compartment syndrome (ACS) affecting this compartment: loss of sensation between the first and second toes, weak foot dorsiflexion. Later foot drop, claw foot and deep peroneal nerve dysfunction may occur.  The most important symptom may be increasing pain, unrelieved by the usual analgesics and pain with passive flexion of the toes.

The deep posterior compartment of the leg contains tibialis posterior, flexor hallucis longus, flexor digitorum longus and poplitius. It also contains the posterior tibial artery and the tibial nerve. Signs of ACS affecting this compartment: plantar hypesthesia, weak to flexion, pain with passive stretch of toes and increasing pain..

The superficial posterior compartment of the leg contains the gastrocnemius, soleus and plantaris muscles. Signs of ACS affecting this compartment: pain and palpably tense compartment.

The lateral compartment of the leg contains the peroneal muscles, longus and brevis. It also contains the peroneal artery and the superficial peroneal nerve. Signs of ACS affecting this compartment: pain and diminished sensation to lower leg in a superficial peroneal nerve distribution, the deep peroneal nerve may also be affected.

The forearm also has four compartments at risk of compartment syndrome -- deep and superficial volar, dorsal and lateral compartments. The volar compartments contain the digital flexors and are at highest risk for compartment syndrome following trauma. ACS is most commonly secondary to distal radius fractures in adults or supracondylar humerus fractures in children.


Cross-section through middle of leg. (Eycleshymer and Schoemaker.)

Would like a cross-section of the leg indicating fascial compartments like this  http://www.uptodate.com/contents/image?imageKey=SURG%2F28260&topicKey=EM%2F358&rank=1~126&source=see_link&search=compartment+syndrome&utdPopup=true

Epidemiology

Compartment syndrome may occur acutely or as a chronic syndrome. At the most basic level, compartment syndrome is elevated pressure within a confined tissue space. Thus, any condition that increases the content or reduces the volume of a compartment could be related to the development of compartment syndrome.

Compartment syndrome occurs because intra-compartmental pressure rises, leading to increased venous pressure and reduced venule diameter. As a result of reduced arteriovenous pressure gradient, there is decreased tissue perfusion. When perfusion can no longer meet the demands of the tissue, necrosis ensues. If the pressure increase continues untreated, irreversible damage to the muscles and nerves within the compartment ensues  .

Chronic compartment syndrome is most commonly seen in athletes and presents as insidious pain. This article will focus primarily on acute compartment syndrome.

Acute compartment syndrome (ACS) is a surgical emergency, most commonly secondary to significant trauma such as a long bone fracture. Specifically, ACS is most commonly seen in patients less than 35 years of age and following either a diaphyseal tibial fracture or a distal radius fracture  .

Supracondylar humerus fractures are the most common cause of ACS in children. While the most common sites are forearm and leg, ACS can also occur in the foot, thigh and gluteal regions.

ACS can also be due to non-traumatic causes such as hemorrhage, fractures, increased capillary permeabiily after burns and post-ischemic swelling {ref:Skeletal Trauma, 4th Ed., Browner, Jupiter, Levine, Trafton and Krettek. Philadelphia: Saunders, Elsevier, 2009.}.

Clinical presentation

Classic Signs:

  1. Pain
  2. Pallor
  3. Pulselessness
  4. Paresthesias
  5. Paralysis

Only pain and paresthesias are early signs. Others occur very late in the process of ACS. Pain out of proportion to the injury is the most common presenting sign. Patients may also experience a deep ache or burning pain.

On examination:

  1. Pain with passive stretch
  2. Tense compartment
  3. Diminished sensation
  4. Weakness / Inability to actively contract muscles within the compartment (later sign).
  5. Paralysis (uncommon).

Pallor from vascular insufficiency (uncommon).

{ref:Skeletal Trauma, 4th Ed., Browner, Jupiter, Levine, Trafton and Krettek. Philadelphia: Saunders, Elsevier, 2009.}.

Red flags

The classic signs point to diagnosis of compartment syndrome. On your clinical rotations this is what you will be asked.

Again:

  1. Pain
  2. Pallor
  3. Pulselessness
  4. Paresthesias
  5. Paralysis

Do not be fooled, compartment syndrome can also be due to compressive external forces such as a cast or circumferential splint or bandage. ACS can occur without trauma.

Watch for difficult to control pain or increasing need for narcotic analgesia.

An open fracture does not preclude compartment syndrome.

Differential diagnosis

Compartment syndrome is a clinical diagnosis – both the clinical exam and measurement of compartment pressures. However, faced with overwhelming clinical evidence, surgical treatment should not be delayed in order to measure compartment pressures. Measurement of serum creatine kinase (CK) is also useful, as this blood marker will rise as muscle injury develops.

In the upper extremity, a common scenario will be to rule out compartment syndrome in the context of IV infiltration and extravasation. 

Objective Evidence

Clinical exam suggestive of compartment syndrome and / or a pressure differential of <30mm Hg.

Detection of compartment syndrome may be difficult as fractures, particularly tibia fractures, are very painful. Additionally, the exam may be complicated by an obtunded or unreliable patient. Whenever there is doubt, compartment pressures should be checked and compared with diastolic blood pressure. The preferred measuring device is the Stryker apparatus (Stryker Intra-compartmental Pressure Monitor System, Kalamazoo, MI).

The most important aspect of diagnosis is to maintain a high index of suspicion in patients at risk for compartment syndrome. The definitive diagnosis of compartment syndrome is made when the difference between intra-compartmental pressure and diastolic blood pressure is less than 30 mm Hg. Normal compartment pressure is 0 – 8 mm Hg. Capillary flow is compromised at 20 mm Hg. Pain develops at 20 – 30 mm Hg. Ischemia develops above 30 mm Hg  . Serial clinical and manometric exam is often indicated to rule out ACS. In the leg, four compartment faciotomies should be performed if the pressure difference is less than 30 mm Hg  .

Risk factors and prevention

Any condition that increases the content or reduces the volume of a compartment can potentially cause a compartment syndrome.

Risk factors include: haemorrhage, fractures, increased capillary permeability (burns), post-ischemia swelling, circumferential dressings, splints or casts.

It is unusual for an acute compartment syndrome to occur in insolation. Most commonly, ACS occurs with a long bone fracture. Whatever the location, the need for fasciotomy is an absolute indication for stabilization of the fracture. 

Treatment options

Immediate management of suspected acute compartment syndrome includes:

  • Relieve all external pressure on the compartment.
  • Remove all dressings, splints, casts or other restrictive coverings.
  • Do not elevate the limb or place it in a dependent position.
  • Give analgesia.
  • Give supplementary oxygen.
  • Treat hypotension, if present, with bolus intravenous fluids.
  • Fasciotomy to fully decompress all involved compartments.
  • Delays in performing fasciotomy lead to increased morbidity.

Fasciotomy should not be performed if the tissue is already dead. The open wound will increase the risk of infection.

{ref: Skeletal Trauma, 4th Ed., Browner, Jupiter, Levine, Trafton and Krettek. Philadelphia: Saunders, Elsevier, 2009.}.

Image showing 1 and 2 incision leg fasciotomies like http://www.uptodate.com/contents/image?imageKey=SURG%2F29162~SURG%2F28262&topicKey=EM%2F358&rank=1~126&source=see_link&search=compartment+syndrome

http://www.uptodate.com/contents/image?imageKey=SURG%2F29162~SURG%2F28262&topicKey=EM%2F358&rank=1~126&source=see_link&search=compartment+syndrome

Outcomes

Current evidence suggests that muscles can tolerate up to 3 hours of warm ischemia before the onset of necrosis. The most important determinant of a poor outcome from acute compartment syndrome is a delayed or missed diagnosis .

In the case of delayed or missed diagnosis, compartment syndrome can result in muscle contractures, sensory deficits, paralysis, infection, fracture non-union and limb amputation.

Rhabdomyolysis may occur with muscle ischemia. This may lead to myoglobinuria and possible renal failure. If this happens the patient may require dialysis.

Holistic medicine

N/A

Miscellany

Acute compartment syndrome is most commonly due to trauma – specifically long bone fracture of the leg or forearm. Non-traumatic acute compartment syndrome is often due to ischemia-reperfusion injury, coagulopathy, animal bites / stings, extravasation of IV fluid, IV drug abuse and prolonged limb compression.

A single normal compartment pressure reading does not rule out acute compartment syndrome. Serial or continuous measurements are often required.

Do not delay treatment.

Key terms

Acute compartment syndrome, fasciotomy, Stryker apparatus.

Skills

Clinical exam to rule out compartment syndrome.

Use of Stryker apparatus.

Content

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