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Updated: Dec 28 2021

Compartment Syndrome

  • 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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