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Acute Compartment Syndrome
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Contents
Other Names
- Compartment Syndrome
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[1]
- Fractures/ Trauma is most common etiology[2]
- 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[3]
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
Risk Factors
- Male > Female
Differential Diagnosis
- Variable depending on area of injury and mechanism
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
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
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%[4]
- 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
Return to Play
- Guided by patients primary recovery
- No clear guidelines
Complications
See Also
References
- ↑ McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82:200–203
- ↑ Mauser N, Gissel H, Henderson C, Hao J, Hak D, Mauffrey C. Acute Lower-leg Compartment Syndrome. Orthopedics. 2013;36:619–624.
- ↑ McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82:200–203.
- ↑ Garfin SR, Mubarak SJ, Evans KL, Hargens AR, Akeson WH. Quantification of intracompartmental pressure and volume under plaster casts. J Bone Joint Surg Am. 1981;63:449–453.
Created by:
John Kiel on 24 June 2019 13:59:56
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Last edited:
31 October 2020 00:29:25
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