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Updated: Apr 2 2020

Compartment Syndrome

  • Snapshot
    • A 21-year-old man presents for evaluation of a painful right leg. He had previously had a tibial fracture and had a tightly bound cast in place. He reports excruciating pain when the cast is released and when the muscles underneath are palpated. A catheter is introduced into the limb and the intracompartmental pressures is 40 mmHg. A surgical consult is immediately called.
  • 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
      • 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
    • Prognosis
      • higher chance of regaining function of the affected limb if a fasciotomy is performed within 12 hours
  • Presentation
    • Symptoms
      • burning pain out of proportion to 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 are classifically associated with compartment syndrome
        • Pallor
        • Pain out of proportion
          • worse with passive stretch
        • Paresthesia
          • “pins and needles” sensation
        • Pulselessness
        • Poikilothermia
        • Paralysis
          • late finding
  • 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 diagnosis if clinicians are unable to elicit the symptoms or history
      • modality
        • a 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 = 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 the 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 mmHg (with lower threshold for compartment syndrome of the hand)
          • prolonged duration of compartment syndrome > 8 hours
  • Complications
    • Volkmann contracture
      • permanent nerve and muscle damage
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