Acute Compartment Syndrome

Other Names

• Compartment Syndrome

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Background

• Occurs when localized compartment pressure exceeds perfusion pressure in a closed osteofascial compartment leading to irreversible muscle and nerve damage if not treated emergently
  • Most commonly associated with fracture of the Tibia
  • Specifically, the Anterior Compartment of the Leg, although all leg compartments can be affected
  • Can occur in any part of upper or lower extremity where muscle is surrounded by fascia

Epidemiology

• 1 to 7.3 per 100,000
• Fractures/ Trauma is most common etiology
• Most commonly occurs in the leg due to tibial fracture, affecting between 2-9% of fractures
• Rhabdomyolysis may occur in nearly 1/4 of cases

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Pathophysiology

• Occurs when compartment pressure exceeds arterial pressure into compartment
• Tissue perfusion represents difference between diastolic blood pressure and compartment pressure

Pathoanatomy

• Local trauma, soft tissue injury
• Subsequent bleeding, swelling and elevated intercompartmental pressure
• As this exceeds perfusion pressure, there is vascular occlusion
• Muscle and neuronal ischemia

Common Etiologies

• Fracture (most common)
• Crush injury
• Immobilizaition
• Snake bites
• Burns
• Prolonged tourniquet application
• Fluid extravasation into a limb
• Soft tissue infection
• Extreme exertion
• Iatroagenic

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Risk Factors

• Male > Female

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Differential Diagnosis

• Variable depending on area of injury and mechanism

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Clinical Features

• Defining feature is pain out of proportion to exam
• Expect patient to have tender, swollen compartment(s)
  • Can be delayed up to 48 hours after inciting event
• In polytrauma, may be missed on initial survey or due to distracting injuries

Classic "5 Ps" of Compartment Syndrome

• • Often tested this way, not as clinically reliable but important to consider
• 1. Pain (early finding)
  • Severe, out of proportion to physical findings
  • Worse with passive movement (muscle extension > increased volume > increased pressure)
  • Often the presenting symptom.
• 2. Paresthesia (early finding)
  • Occurs in sensory distribution of affected nerve
• 3. Pallor
• 4. Paralysis: late finding
• 5. Pulselessness: late finding

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Evaluation

Imaging

• Radiographs to evaluate for fracture

Compartment Pressure Testing

• Lack of clear diagnostic criteria
• < 20 mm Hg generally considered "normal"
• Compartment pressure > 30 may be pathologic
  • Must be taken in clinical context
• Delta pressure may be more accurate
  • Diastolic pressure - compartment pressure
• If clinical index of suspicion is high, surgical intervention may be indicated regardless of compartment pressure measurements

Laboratory

• Evaluate for muscle injury, including Rhabdomyolysis
  • Creatinine Kinase
  • Urinalysis
• Metabolic panel
  • Check postassium, kidney function

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Management

Nonoperative

• Decision to manage acute compartment nonoperatively should be made by surgical team
• Cast, splint and any compression dressing should be immediately removed which can reduce ICP by up to 65%
• Serial examinations should be performed

Fasciotomy

• Should not be delayed if clinical suspicion high or diagnosis confirmed
  • >8 hours of ischemia associated with permanent injury

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Return to Play

• Guided by patients primary recovery
• No clear guidelines

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Complications

• Rhabdomyolysis
• Hyperkalemia
• Foot Drop

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See Also

• Fractures (Main)
• Trauma

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