Acute Compartment Syndrome
Other Names
- Compartment Syndrome
- Acute Compartment Syndrome (ACS)
Background
- This page refers to acute compartment syndrome (ACS) which occurs when compartment pressure exceeds arterial pressure into compartment, typically due to trauma
History
- Needs to be updated
Epidemiology
- 1 to 7.3 per 100,000[1]
- Fractures/ Trauma is most common etiology[2]
- Accounts for 75% of cases
- 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[1]
Introduction
General
- 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
- Tissue perfusion represents difference between diastolic blood pressure and compartment pressure
- This is a life threatening condition and surgical emergency[4]
- All key structures within the compartment can be affected including muscle, nerve and vasculature
- Delay in diagnosis or treatment can result in irreversible damage
Pathophysiology
- General
- 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
- Arteriovenous Pressure Gradient theory (APG)[5]
- ACS occurs when blood flow does not meet the metabolic demands of affected tissues with subsequent tissue ischemia
- Cascade of events occur: increased inflammation, arterial spasm, disrupted capillary flow, increased osmotic pressure, proteinaceous exudate, muscle fiber swelling, and edema
- Without intervention, cycle self propagates and contributes further to increased ICP
- Consequently, there is continual rise in edema within the compartment enclosed in an fixed, inexpandable fascia
- As ICP increases, tissue and venous pressure compromises capillary function with muscle and nerve ischemia occurring
- Without surgical decompression, irreversible pressure-induced ischemia results in tissue and cellular death
Common Etiologies
- Orthopedic[6]
- Tibial Shaft Fracture
- Blunt or Penetrating Trauma
- Total knee arthroplasty
- Vascular
- Reperfusion therapy
- Arterial puncture or injury
- Hemorrhage
- Deep Vein Thrombosis
- Soft Tissue
- Crush injury
- Contusion
- Burn
- Envenomation (Snake Bite)
- Iatrogenic
- Drugs (Anticoagulants)
- Bleeding Disorders (Sickle cell)
- Casts or Splints
- Constrictive Dressings
- Extravasation of drugs and fluids
- Prolonged lithotomy positioning
- Viral myositis
- Diabetic muscle infarction
- There are 4 compartments in the lower leg: anterior, lateral, superficial posterior, deep posterior
- Each compartment contains specific nerves, arteries, veins, muscles and bony structures that can contribute to the clinical presentation of ACS
- It is critical to know and understand the structures in each compartment to effectively assess and diagnose ACS
Risk Factors
- Male > Female[7]
Differential Diagnosis
- Variable depending on area of injury and mechanism
Clinical Features
General
- Diagnosis is largely based on clinical exam
- 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
- Early recognition is critical and requires a high index of suspicion
Classic "5/6 Ps" of Compartment Syndrome
- General
- Often tested on exams this way
- Not universally present in each patient
- Pain (early finding)
- Severe, out of proportion to physical findings
- Worse with passive movement (muscle extension > increased volume > increased pressure)
- Often the presenting symptom.
- Paresthesia (early finding)
- Occurs in sensory distribution of affected nerve
- Pallor
- Paralysis: late finding
- May occur as early as 30 minutes[8]
- Loss of light touch often precedes limb weakness
- Pulselessness: late finding
- Late finding with poor prognosis
- Arterial insufficiency is not typically present initially, both DP and PT pulses are typically palpable
- Cap refill is brisk early
- Poikilothermia
- Change in temperature or presence of coolness to the affected limb
Evaluation
Imaging
- Radiographs to evaluate for fracture
Compartment Pressure Testing
- If possible, measure all 4 compartments
- Compare to contralateral limb
- Normal
- < 20 mm Hg generally considered "normal"
- Normal resting limb compartment pressure is 0 to 4 mm Hg
- It may increase up to 10 mm Hg physiologically with exertion
- Pathologic
- Lack of clear diagnostic criteria
- Compartment pressure > 30 may be pathologic
- Must be taken in clinical context
- Within 8 hours at 30 mm Hg, nerve conduction is disrupted
- Higher pressures accelerate damage to compartment pressure structures
- Delta pressure may be more accurate
- Diastolic pressure - compartment pressure
- Delta pressure less than or equal to 30 mm Hg is considered diagnostic
- 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%[10]Masquelet, A-C. "Acute compartment syndrome of the leg: pressure measurement and fasciotomy." Orthopaedics & Traumatology: Surgery & Research 96.8 (2010): 913-917.</ref>]]
- Serial examinations should be performed
- Elevation of extremity no higher than the level of the heart facilitates venous drainage, reduces edema and maximize tissue perfusion
- Avoid knee flexion (can limit circulation) and dorsiflexion (limit perfusion of deep posterior compartment)
Fasciotomy
- Should not be delayed if clinical suspicion high or diagnosis confirmed
- >8 hours of ischemia associated with permanent injury
Rehabilitation and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/Work
- Guided by patients primary recovery
- No clear guidelines
Prognosis and Complications
Acute Complications
- Rhabdomyolysis
- Hyperkalemia
- Sepsis
- Multi-organ failure
- Death
Chronic Complications
- Foot Drop
- Contractures
- Paralysis
- Amputation
See Also
Internal
External
References
- ↑ 1.0 1.1 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.
- ↑ 3.0 3.1 3.2 Pechar, Joanne, and M. Melanie Lyons. "Acute compartment syndrome of the lower leg: a review." The Journal for Nurse Practitioners 12.4 (2016): 265-270.
- ↑ Donaldson J, Haddad B, Khan WS. The pathophysiology, diagnosis and current management of acute compartment syndrome. Open Orthop J. 2014;8:185–193.
- ↑ Murdock M, Murdoch MM. Compartment syndrome: a review of the literature. Clin Podiatr Med Surg. 2012;29:301–310. viii.
- ↑ Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg. 2007;73:1199–1209.
- ↑ Mauser N, Gissel H, Henderson C, Hao J, Hak D, Mauffrey C. Acute lower-leg compartment syndrome. Orthopedics. 2013;36:619–624.
- ↑ Bowyer MW. Compartment Syndrome. In: Gahtan V, Costanza MJ, editors. Essentials of Vascular Surgery for the General Surgeon. Springer; New York: 2014. pp. 55–69.
- ↑ Masquelet, A-C. "Acute compartment syndrome of the leg: pressure measurement and fasciotomy." Orthopaedics & Traumatology: Surgery & Research 96.8 (2010): 913-917.
- ↑ 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.