Compartment Syndrome

What is compartment syndrome?

An elevation of the interstitial pressure in a closed osseofascial compartment resulting in microvascular compromise

 Compartment syndrome can develop anywhere skeletal muscle is surrounded by substantial fascia Most commonly seen in anterior and deep posterior compartments of the leg and the volar compartment of the forearm

Acute or Chronic?
Depends on the cause of increased pressure and duration of symptoms

Acute Compartment Syndrome

Most common causes
Fractures Soft tissue trauma Arterial injury Limb compression during altered consciousness Burns

Chronic compartment syndrome

Chronic exertional compartment syndrome
Recurrence of increased pressure Most commonly seen in anterior or deep posterior compartment of the leg
Most common in long distance runners

Also reported to occur in forearms of weightlifters

Exertional compartment syndrome

Pathophysiology
Insult to normal local tissue homeostasis Results in increased tissue pressure Decreased capillary blood flow Local tissue necrosis caused by oxygen deprivation

Pathophysiology
Local blood flow is equal to the arteriovenous gradient divided by local vascular resistance LBF = (Pa-Pv)/R Under ischemic conditions, local vascular resistance is minimal and arterial blood flow is maximized

Pathophysiology
Significant muscle necrosis can occur in patients with normal blood flow if intracompartmental pressure is increased to more than 30mmHg for longer than 8 hrs

Acute compartment syndrome

Signs (the Ps)
Pain Paresthesia paralysis Pallor Poikilothermia Pulselessness

Diagnosis
Compartment pressures greater than 30 mm Hg
Collinge and Person study: erroneous pressure measurements obtained in 27% of muscle compartments in pts with lower limb trauma

May also use <30mm Hg difference between compartment pressure and diastolic BP* May be delayed in multiply injured patients, pts with altered consciousness, and children
May require serial compartment measurements

Prevention?
If incipient compartment syndrome is suspected, several procedures can be used to decrease the likelihood of development of full-blown compartment syndrome
Colloid or crystalloid fluids Blood replacement Maintenance of coagulability by replacement of platelets and plasma

Prevention
Swartz et. al. listed factors contributing to development of compartment syndrome in the thigh
Multiple injuries Systemic hypotension History of external compression of the thigh Use of military anti-shock trousers Coagulopathy Vascular injury Trauma to the thigh with or without femoral fractures

Case Scenario
25 M P2 trauma s/p ATV accident, +EtOH, altered mental status on arrival. closed L tib/fib fx. Splint placed by the intern. Pt admitted to floor.

Case scenario cont

6 hrs later, nurse pages saying pt is in unbearable pain after 2 percocets and 0.4mg dilaudid. Pt is screaming and disrupting other patients, nurse is frustrated and requests you to evaluate patient.

Case scenario cont

When you enter room, pt is angry and screaming. Splint is intact Exam:
Pt c/o tingling in all toes of LLE Sluggish cap refill Extreme pain with movement of toes

Now what?

Case scenario cont

Split the circular dressings
Can decrease compartment pressures by 50-85%

Positioning
Elevation of the affected limb above the level of the heart produces the highest A-V gradient

After splitting the dressings, pt reports immediate decrease in tingling, cap refill improves. Life is good.

Case scenario cont

1 hr later, nurse pages again saying pt is again screaming. You re-evaluate, LLE is painful with toe movement, sluggish cap refill, decreased temp compared to contralateral limb You measure compartment pressures, which are 40 mm Hg in anterior, 37mm Hg lateral, 38 mm Hg in posterior and deep posterior compartments; BP is 110/65

 Pt taken to OR emergently for fasciotomy

Case Scenario cont

Fasciotomy
Single incision
Useful if soft tissue of the limb is not extensively distorted

Double incision
Safe, effective

Fibulectomy
Radical procedure, rarely done or indicated for ACS

If done within 25-30 hrs after onset, prognosis is good

Little or no return of function can be expected if diagnosis and treatment are delayed No benefit from fasciotomy has been reported after 3rd-4th day If done late, severe infections have been reported to occur in the necrotic muscle of many patients

Life after fasciotomy

Return to OR in 48-72 hrs for debridement of any necrotic tissue If no evidence of necrosis, skin is loosely closed If closure is not accomplished, debridement is repeated in another 48-72 hrs
Skin closure or grafting can be done at this time

Life after fasciotomy cont

Wound management
Primary closure Healing by secondary intention Split thickness skin grafting
Necessary in 50% of patients

Delayed primary closure

Vessel loop shoelace technique

Other treatments
Hyperbaric oxygen
Addresses primary concern of ischemic injury Reduces edema through oxygen-induced vasoconstriction Maintains oxygen perfusion and supports tissue healing Watter et al concluded that HBO improves wound healing, reducing amputation rate and lowers surgical procedure rate Currently only adjunctive therapy because of limited availability

Complications
Permanent nerve damage Volkmanns contracture Infection Cosmetic deformity from fasciotomy Loss of limb Rhabdomylosis Kidney injury/failure death

volkmanns contracture