Updated: 12/28/2021

Compartment Syndrome

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  • Snapshot
    • A 21-year-old, previously healthy man presents for evaluation of a painful left leg approximately 5 hours after his leg got caught between closing elevator doors. He did not have pain immediately after the leg trauma. However, he currently has 10/10 pain. Physical exam reveals pain with dorsiflexion of his left foot and tenderness in his calf. Posterior tibial and dorsalis pedis pulses are present bilaterally. The surgical service is consulted immediately for urgent fasciotomy of his left foot.
  • Introduction
    • Clinical definition
      • a painful emergency condition that occurs when the tissue pressure inside an anatomical compartment, bound by fascia, exceeds the perfusion pressure, resulting in ischemia and necrosis
  • Epidemiology
    • Location
      • lower extremity > upper extremity
      • leg
      • forearm
      • hand
      • foot
      • thigh
    • Risk factors
      • trauma
      • anticoagulation therapy
      • bleeding disorders
  • Etiology
    • The most common cause is a fracture
      • tibia fracture
    • Soft tissue injury
    • Circumferential burns
    • Crush injuries
    • Constrictive dressing (e.g., splints, casts, or poor surgical positioning)
    • Penetrating wounds
    • Pathogenesis
      • blood flow is blocked when the tissue pressure exceeds the perfusion pressure within a fixed-volume compartment
      • this results in a lack of oxygen and the accumulation of waste products, causing pain and decreased peripheral sensation
        • irreversible tissue damage occurs between 6-8 hours after onset
      • after a period of ischemia, tissue reperfusion generates toxic reactive oxygen species and other inflammatory mediators that cause increased capillary permeability and interstitial edema 
        • increased edema leads to rising compartment pressures, which can cause compartment syndrome
        • limb ischemia-reperfusion injury
  • Presentation
    • Symptoms
      • burning pain out of proportion to the injury
        • the most specific and important symptom
      • pain with active contraction of the compartment
      • may have paresthesia or numbness
    • Physical exam
      • firm, swollen, and wooden feeling of the muscles on palpation
      • may have skin findings such as bullae
      • ↓ vibration sensation
      • ↓ 2-point discrimination
      • 6 P’s only manifest in the late stages of the syndrome
        • Pallor
        • Pain out of proportion
          • worse with passive stretch
        • Paresthesia
          • “pins and needles” sensation
        • Pulselessness
        • Poikilothermia
        • Paralysis
  • Imaging
    • Radiography
      • indication
        • typically not needed for diagnosing compartment syndrome, but useful for characterizing any trauma such as fractures
  • Studies
    • Compartment pressure measurement
      • indication
        • to confirm the diagnosis if clinicians are unable to elicit the symptoms or history
      • modality
        • the transducer is connected to a catheter and is used to measure the intracompartmental pressure (ICP)
    • Making the diagnosis
      • most cases are clinically diagnosed or guided by pressure measurement
        • absolute ICP > 30 mm Hg
        • Δ pressure (diastolic blood pressure - ICP) < 30 mmHg
          • normal ICP is 0 mm Hg
  • Differential
    • Cellulitis
      • distinguishing factor
        • normal neurovascular exam
    • Rhabdomyolysis
      • distinguishing factors
        • abnormal laboratory evaluation, including creatine phosphokinase, renal function studies, urine myoglobin, and potassium
  • Treatment
    • Management approach
      • management is focused on early decompression
      • observation and conservative management is appropriate only if ICPs are not high
    • Conservative
      • place limb at the level of the heart without elevation
        • indication
          • for all patients while awaiting diagnosis or decompression
      • immediate removal of any wraps, splints, or casts
        • indication
          • for all patients
      • immobilization
        • indication
          • for all patients
    • Operative
      • fasciotomy
        • indications
          • ICP > 30 mm Hg (with lower threshold for compartment syndrome of the hand)
          • prolonged duration of compartment syndrome > 8 hours
  • Complications
    • Volkmann contracture
      • permanent nerve and muscle damage
    • Acute kidney injury
  • Prognosis
    • Higher chance of regaining function of the affected limb if a fasciotomy is performed within 12 hours
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Questions (9)
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(M2.OR.17.4799) A 23-year-old patient presents to the emergency department after a motor vehicle accident. The patient was an unrestrained driver involved in a head-on collision. The patient is heavily intoxicated on what he claims is only alcohol. An initial trauma assessment is performed, and is notable for significant bruising of the right forearm. The patient is in the trauma bay, and complains of severe pain in his right forearm. A physical exam is performed and is notable for pallor, decreased sensation, and cool temperature of the skin of the right forearm. Pain is elicited upon passive movement of the right forearm and digits. A thready radial pulse is palpable. A FAST exam is performed, and is negative for signs of internal bleeding. The patient's temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 110/70 mmHg, respirations are 12/min, and oxygen saturation is 98% on room air. Radiography of the right forearm is ordered. The patient is still heavily intoxicated. Which of the following is the best next step in management?

QID: 109322

Detoxification

0%

(0/34)

IV fluids

12%

(4/34)

Analgesics

9%

(3/34)

Fasciotomy

65%

(22/34)

Pressure measurement

12%

(4/34)

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(M2.OR.16.4690) A 40-year-old patient is brought into the emergency department after suffering a motor vehicle crash where he was pinned underneath his motorcycle for about 30 minutes before a passerby called 911. While evaluating him per your institution's trauma guidelines, you discover pain upon palpation of his right lower extremity which is much larger than his left counterpart. The patient admits to decreased sensation over his right lower extremity and cannot move his leg. There are no palpable dorsalis pedis or posterior tibial pulses on this extremity, and it is colder and paler in comparison to his left side. Measured compartment pressure of his distal right leg is 35 mm Hg. What is the next best step in this patient's care?

QID: 107586

Emergent fasciotomy

90%

(9/10)

Venous doppler

0%

(0/10)

Arteriogram

10%

(1/10)

External fixation

0%

(0/10)

Internal fixation

0%

(0/10)

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(M2.OR.16.161) A 25-year-old patient is brought into the emergency department after he was found down by the police in 5 degree celsius weather. The police state the patient is a heroin-user and is homeless. The patient's vitals are T 95.3 HR 80 and regular BP 150/90 RR 10. After warming the patient, you notice his left lower leg is now much larger than his right leg. On exam, the patient has a loss of sensation on his left lower extremity. There is a faint palpable dorsalis pedal pulse, but no posterior tibial pulse. The patient is unresponsive to normal commands, but shrieks in pain upon passive stretch of his left lower leg. What is the most probable cause of this patient's condition?

QID: 104167

Cellulitis

15%

(2/13)

Necrotizing fasciitis

15%

(2/13)

Embolized clot

23%

(3/13)

Reperfusion associated edema

46%

(6/13)

Diabetes

0%

(0/13)

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