Compartment syndrome is a life-threatening condition of the limbs which occurs after
an injury, when there is insufficient blood supply to muscles and nerves due to increased
pressure within one of the body's compartments, such as an arm, leg or other enclosed space
within the body. If uncorrected, the lack of blood supply leads to injury in the affected
muscles and nerves. The severity of compartment syndrome can be divided into acute, subacute,
and chronic compartment syndrome with acute severity usually requiring amputation of the
affected limb.
Signs and symptoms Classically, there are 6 "Ps" associated with
compartment syndrome – pain out of proportion to what is expected based on the physical
exam findings, paresthesia, pallor, paralysis, pulselessness, and poikilothermia. The first
signs of compartment syndrome are numbness, tingling and paresthesia. Loss of function,
and decreased pulses or pulselessness however, are late signs. According to Shears paresthesia
in the distribution of the nerves transversing the affected compartment has also been described
as relatively early sign of compartment syndrome, and later is followed by anesthesia. The other
three symptoms of compartment syndrome are palpable pulse, paresis and pallor. These
symptoms are irreversible and consistent during compartment syndrome and they are part of
the diagnosis. Pain is often reported early and almost universally.
The description is usually of deep, constant, and poorly localized pain out of proportion
with the findings on physical examination. The pain is aggravated by passively stretching
the muscle group within the compartment or actively flexing it and is not relieved by
analgesia up to and including morphine. Paresthesia in the cutaneous nerves of the
affected compartment is another typical sign. Paralysis of the limb is usually a late finding.
The compartment may also feel very tense and firm. Some find that their feet and even legs
fall asleep. This is because compartment syndrome prevents adequate blood flow to the rest of
the leg. A lack of pulse rarely occurs in patients,
as pressures that cause compartment syndrome are often well below arterial pressures and
pulse is only affected if the relevant artery is contained within the affected compartment.
Tense and swollen shiny skin, sometimes with obvious bruising of the skin.
Congestion of the digits with prolonged capillary refill time.
Causes Because the fascia layer that defines the
compartment does not stretch, a small amount of bleeding into the compartment, or swelling
of the muscles within the compartment, can cause the pressure to rise greatly. Common
causes of compartment syndrome include tibial or forearm fractures, ischemic reperfusion
following injury, hemorrhage, vascular puncture, intravenous drug injection, casts, prolonged
limb compression, crush injuries and burns. Less common causes include labor and delivery
following uncomplicated births and csections. Compartment syndrome can also occur following
surgery in the Lloyd-Davies lithotomy position, where the patient's legs are elevated for
prolonged periods. As of February 2001, any surgery that is expected to take longer than
six hours to complete must include compartment syndrome on its list of post-operative complications.
The Lloyd Davis lithotomy position can cause extra pressure on the calves and on the intermittent
pneumatic compression device worn by the patient. When compartment syndrome is caused by repetitive
use of the muscles, as in a cyclist, it is known as chronic compartment syndrome. This
is usually not an emergency, but the loss of circulation can cause temporary or permanent
damage to nearby nerves and muscles. The cause of compartment syndrome is due to excess pressure
on or within the muscle compartments. This pressure can occur for many different reasons,
many are due to injuries. Injuries cause the swelling of tissue. The swelling of the tissue
forces pressure upon the muscle compartments, which has a limited volume. Due to this pressure,
the venules and lymphatic vessels that drain the muscle compartments are compressed, and
are prevented from draining. As arterial inflow continues while outflow is decreased, the
pressure builds up in the muscle compartments. This pressure will eventually decrease the
amount of blood flow over the capillary bed, causing the tissue to become ischaemic. The
tissues will release factors and will lead to the formation of edema.
Complementary to chronic compartment syndrome is another subset known as chronic exertional
compartment syndrome CECS, often called exercise induced compartment syndrome EICS [17]. According
to Touliopolous, CECS of the leg is a condition caused by exercise which results in increase
tissue pressure within a limited fibro – osseous compartment – muscle size may increase by
up to 20% during exercise When this happens pressure builds up in the tissues and muscles
causing tissue ischemia. An increase in muscle weight will reduce the compartment volume
of the surrounding fascial borders and resulting in an increase of intracompartmental pressure.
An increase in the pressure of the tissue can cause fluid to exude into the small spaces
between the tissue known as interstitial space, leading to a disruption of the micro-circulation
of the leg. This condition occurs commonly in the lower leg and various other locations
within the body, such as the foot or forearm[18]. This is commonly seen in athletes who train
rigorously in activities that involve constant repetitive actions or motions[17]. Symptoms
involve numbness or a tingling sensation in the area most affected[18]. Other signs and
symptoms include pain described as aching, tightening, cramping, sharp, or stabbing.
This pain can occur for months, and in some cases over a period of years, and are often
relieved by rest. It also includes moderate weakness that can be a noticeable factor in
the affected region[18]. Chronic exertional compartment syndrome most commonly affects
the anterior compartment of the leg, this can lead to problems with dorsiflexion of
the ankle and the toes. The symptoms of CECS are often confused with more common injuries
like shin splints and spiral stenosis. Treatment for chronic exertional compartment syndrome
includes decreasing or subsiding exercising and activities, or cross training for athletes[17].
Pathophysiology During compartment syndrome there is increased
intra-compartmental pressure in the interstitium over its capillary perfusion pressure, due
to the accumulation of necrotic debris and haemorrhage, especially haemorrhage secondary
to fractures. Any condition that results in an increase in compartment contents or reduction
in a compartment’s volume can lead to the development of an acute compartment syndrome.
When pressure is elevated, capillary blood flow is compromised. Edema of the soft tissue
within the compartment further raises the intra-compartment pressure, which compromises
venous and lymphatic drainage of the injured area. Pressure, if further increased in a
reinforcing vicious circle, can compromise arteriole perfusion, leading to further tissue
ischemia. Untreated compartment syndrome-mediated ischemia of the muscles and nerves leads to
eventual irreversible damage and death of the tissues within the compartment. There
are three main mechanisms that are hypothesized to cause compartment syndrome. One idea is
the increase in arterial pressure causes the arteries to spasm and this causes the pressures
in the muscle to increase even further. Second, obstruction of the microcirculatory system
is hypothesized. Finally, there is the idea of arterial or venous collapse due to transmural
pressure. Acute compartment syndrome of the lower extremity
is a clinical condition that is seen fairly regularly in modern practice. Although pathophysiology
of the disorder is well known to physicians who care for patients with musculoskeletal
injuries, the diagnosis is often difficult to make. If left untreated, acute compartment
syndrome can lead to more severe conditions including rhabdomyolysis and kidney failure
potentially leading to death. Diagnosis
Compartment syndrome is a clinical diagnosis. However, it can be tested for by gauging the
pressure within the muscle compartments. If the pressure is sufficiently high, a fasciotomy
will be required to relieve the pressure. Various recommendations of the intracompartmental
pressure are used with some sources quoting >30 mmHg as an indication for fasciotomy
while others suggest a <30 mmHg difference between intracompartmental pressure and diastolic
blood pressure. This latter measure may be more sensible in the light of recent advances
in permissive hypotension, which allow patients to be kept hypotensive in resuscitation. It
is now relatively easy to measure compartment and subcutaneous pressures using the pressure
transducer modules that are attached to most modern anaesthetic machines. Most commonly
compartment syndrome is diagnosed through a diagnosis of its underlying cause and not
the condition itself. According to Blackman one of the tools to diagnose compartment syndrome
is X-ray to show a tibia/fibula fracture, which when combined with numbness of the extremities
is enough to confirm the presence of compartment syndrome.
Treatment Acute compartment syndrome
Acute compartment syndrome is a medical emergency requiring immediate surgical treatment, known
as a fasciotomy, to allow the pressure to return to normal. Although only one compartment
is affected, fasciotomy is done to release all compartments. For instance, if only the
deep posterior compartment of a leg is affected, the treatment would be fasciotomy to release
all compartments of the leg in question, namely the anterior, lateral, superficial posterior
and deep posterior. An acute compartment syndrome has some distinct features such as swelling
of the compartment due to inflammation and arterial occlusion. Decompression of the nerve
traversing the compartment might alleviate the symptoms.
Subacute compartment syndrome Subacute compartment syndrome, while not quite
as much of an emergency, usually requires urgent surgical treatment similar to acute
compartment syndrome. Chronic compartment syndrome
Chronic compartment syndrome in the lower leg can be treated conservatively or surgically.
Conservative treatment includes rest, anti-inflammatories, and manual decompression. Elevation of the
affected limb in patients with compartment syndrome is contraindicated, as this leads
to decreased vascular perfusion of the affected region. Ideally, the affected limb should
be positioned at the level of the heart. The use of devices that apply external pressure
to the area, such as splints, casts, and tight wound dressings, should be avoided. In cases
where symptoms persist, the condition can be treated by a surgical procedure, subcutaneous
fasciotomy or open fasciotomy. Left untreated, chronic compartment syndrome can develop into
the acute syndrome. A possible complication of surgical intervention for chronic compartment
syndrome can be chronic venous insufficiency. Hyperbaric oxygen therapy has been suggested
by case reports – though as of 2011 not proven in controlled randomized trials – to
be an effective adjunctive therapy for crush injury, compartment syndrome, and other acute
traumatic ischemias, by improving wound healing and reducing the need for repetitive surgery.
The main treatment for compartment syndrome is surgical. Incisions are made in the affected
muscle compartments so that they will decompress. This decompression will relieve the pressure
on the venules and lymphatic vessels, and will increase bloodflow throughout the muscle.
Complications Failure to relieve the pressure can result
in necrosis of tissue in that compartment, since capillary perfusion will fall leading
to increasing oxygen deprivation of those tissues. This can cause Volkmann's contracture
in affected limbs. As intercompartmental pressure rises during compartment syndrome, perfusion
within the compartment is reduced leading to ischemia, which if left untreated, results
in necrosis of nerves and muscles of the compartment. Rhabdomyolysis and subsequent renal failure
are also possible complications. Notable cases
PBS science correspondent Miles O'Brien suffered a compartment syndrome and had to have his
left arm amputated. According to his blog, O'Brien was securing cases filled with camera
gear on a cart as he wrapped up a reporting trip to Japan and the Philippines. One fell
on his arm. The arm was sore and swollen the next day but worsened on the next, Feb. 14,
2014, and he sought medical care. At the hospital, as his pain increased and arm numbness set
in, a doctor recommended an emergency procedure to relieve the pressure within the limb, O'Brien
wrote. The doctor made a real-time call and amputated his arm just above the elbow.
See also Abdominal compartment syndrome
Escharotomy Volkmann's contracture
References
17 "Compartment Syndrome – OrthoInfo – AAOS." Compartment Syndrome – OrthoInfo – AAOS.
N.p., n.d. Web. 07 Dec. 2013.
18. Paik, Ronald S., Douglas Pepples, and Mark R. Hutchinson. "Chronic exertional compartment
syndrome." pain 78: 136–42. Further reading
Ahmet Bayar, MD; Selcuk Keser, MD; Mubin Hosnuter, MD; H. Alper Tanriverdi, MD; Ahmet Ege, MD.
"Lower Limb Compartment Syndrome After an Uncomplicated Labor". Orthopedics. November
2007 – Volume 30 · Issue 11 Floyd R. and Thompson C. Manual of Structural
Kinesiology 17th Ed., McCrawHill. ISBN 978-0-07-337643-1 Blackman, Paul G.. "A review of chronic exertional
compartment syndrome in the lower leg." Medicine and Science in Sports and Exercise 32.3: S4-S10.
Hamill, J and Knutzem KM. Biomechanical Basis of Human Movement, 3rd Ed. Lippincott Williams&Wilkins.
ISBN 978-0-7817-9128-1 Leung, Y.F., Ip, S.P., Chung, O.M., Wai, Y.L.,.
Unimuscular neuromuscular insult of the leg in partial anterior compartment syndrome in
a patient with combined fractures. Hong Kong Medical Journal, 9.
Rankin, E.A., Andrews, G.. Anterior tibial compartmental syndrome: an unusual presentation.
Journal of the National Medical Association, 73.
Rorabeck, C.H.,. The treatment of compartment syndromes of the leg. Journal of Bone and
Joint Surgery-British, 66-B. Retrieved from http:web.jbjs.org.ukcontent66-B93
Shadgan, B., et al.. Current thinking about acute compartment syndrome of the lower extremity,
Canadian Journal of Surgery, 53. Shears, E., Porter, K.. Acute compartment
syndrome of the limb. Trauma, 8. Touliopolous, S., Hershman, E.B.,. Lower leg
pain: diagnosis and treatment of compartment syndromes and other pain syndromes of the
leg. Sports Medicine, 27. External links
Compartment Syndrome of the Forearm – Orthopaedia.com Chronic Exertional Compartment Syndrome detailed
at MayoClinic.com Compartment_syndrome at the Duke University
Health System's Orthopedics program 05-062a. at Merck Manual of Diagnosis and
Therapy Home Edition Fasciotomy, Chronic Venous Insufficiency,
and the Calf Muscle Pump Compartment syndrome
Saphenous nerve injury after fasciotomy for compartment syndrome
American Association of Orthopaedic Surgeons Compartment Syndrome