Updated: 4/2/2020

Compartment Syndrome

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Topic
https://upload.medbullets.com/topic/110025/images/04012020vldcompartmentsyndrome.jpg
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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Questions (2)
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(M1.MK.14.66) A 17-year-old male presents to the emergency department after a knife fight. He initially refused to come to the hospital, but one of his wounds overlying the right antecubital fossa would not stop bleeding. Vitals include: BP 90/65, HR 115, and RR 24. He reports that he is light-headed and having visual changes. You hold direct pressure over the wound on his right arm while the rest of the team resuscitates him with crystalloid and pRBCs. After his vitals signs normalize, you note that his right arm is cool and you are unable to palpate a radial pulse. The vascular surgery team explores his right arm, finding and repairing a lacerated brachial artery. Two hours post-operatively he is complaining of 10/10 pain in his right forearm and screams out loud when you passively move his fingers. What is the most appropriate next step in management?

QID: 104608
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Watchful waiting

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(0/64)

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Increase his dose of hydromorphone

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(4/64)

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Compressive bandage

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(2/64)

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Measure forearm compartment pressures

70%

(45/64)

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Nerve block

19%

(12/64)

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