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Acute Compartment Syndrome

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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

  1. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82:200–203
  2. Mauser N, Gissel H, Henderson C, Hao J, Hak D, Mauffrey C. Acute Lower-leg Compartment Syndrome. Orthopedics. 2013;36:619–624.
  3. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82:200–203.
  4. 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
Authors:
Last edited:
31 October 2020 00:29:25
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