Acute Compartment Syndrome

Article Author:
Allison Torlincasi
Article Author (Archived):
Kristina Soman-Faulkner
Article Editor:
Muhammad Waseem
Updated:
4/17/2019 11:44:09 PM
PubMed Link:
Acute Compartment Syndrome

Introduction

Acute compartment syndrome occurs when there is increased pressure within a closed fascial compartment, resulting in impaired local circulation. Acute compartment syndrome is considered a surgical emergency since without proper treatment it can lead to ischemia and eventually necrosis. Generally, acute compartment syndrome is considered a clinical diagnosis, however intracompartmental pressure (ICP) > 30 mmHg can be used as a threshold to aid in diagnosis. However, a single normal ICP reading does not exclude acute compartment syndrome. 

Fascia is a thin, inelastic sheet of connective tissue that surrounds muscle compartments and limits the capacity for rapid expansion. In the leg, there are four muscle compartments: anterior, lateral, deep posterior, and superficial posterior. The anterior compartment of the leg is the most common location for compartment syndrome. This compartment contains the extensor muscles of the toes, the tibialis anterior muscle, the deep peroneal nerve, and the tibial artery. 

Other locations in which acute compartment syndrome is seen include the forearm, thigh, buttock, shoulder, hand, and foot. It can also be seen in the abdomen, but that is reviewed in a separate article.

Etiology

Acute compartment syndrome can occur with any condition that restricts the intracompartmental space or increases the fluid volume in the intracompartmental space. Acute compartment syndrome can occur without any precipitating trauma but typically occurs after a long bone fracture, with tibial fractures being the most common cause of the condition, followed by distal radius fractures. Seventy-five percent of cases of acute compartment syndrome are associated with fractures. After fractures, the most common cause of acute compartment syndrome is soft tissue injuries. Burns, vascular injuries, crush injuries, drug overdoses, reperfusion injuries, thrombosis, bleeding disorders, infections, improperly placed casts or splints, tight circumferential bandages, penetrating trauma, intense athletic activity, and poor positioning during surgery are some of the other causes of acute compartment syndrome. 

In children, supracondylar fractures of the humerus and both ulnar and radial forearm fractures are associated with compartment syndrome.

Epidemiology

The incidence of acute compartment syndrome is estimated to be 7.3 per 100,000 in males and 0.7 per 100,000 in females, with the majority of cases occuring after trauma. Tibial shaft fractures, the most common cause of acute compartment syndrome, are associated with a 1-10 percent incidence of acute compartment syndrome.

Acute compartment syndrome occurs more commonly in males younger than 35, which may be due to a larger relative intracompartmental muscle mass and increased likelihood of being involved in high energy trauma.

Patients with bleeding diathesis such as hemophilia are at greater risk for acute compartment syndrome. Cases of acute compartment syndrome have been reported without acute precipitating trauma in pediatric leukemia. 

Pathophysiology

Acute compartment syndrome occurs due to decreased intracompartmental space or increased intracompartmental fluid volume, because the surrounding fascia is inherently noncompliant. As the compartment pressure increases, hemodynamics are impaired. There is normally an equilibrium between venous outflow and arterial inflow. When there is an increase in compartmental pressure, there is a reduction in venous outflow. This causes venous pressure and thus venous capillary pressure to increase. If the intracompartmental pressure becomes greater than arterial pressure, a decrease in arterial inflow will also occur. The decrease of venous outflow and arterial inflow result in decreased oxygenation of tissues causing ischemia. If the deficit of oxygenation becomes great enough then, irreversible necrosis may occur.

The normal pressure within a compartment is less than 10 mmHg. If the intracompartmental pressure reaches 30 mmHg or greater, acute compartment syndrome is present. However, a single normal ICP reading does not exclude acute compartment syndrome; ICP should be monitored serially or continuously.

History and Physical

Acute compartment syndrome typically occurs within a few hours of inciting trauma, however, it can present up to 48 hours after. The earliest objective physical finding is the tense, or "wood-like" feel of the involved compartment. Pain is typically severe, out of proportion to the injury. Early on, pain may only be present with passive stretching. However, this symptom may be absent in advanced acute compartment syndrome. In the initial stages, pain may be characterized as a burning sensation or as a deep ache of the involved compartment. Paresthesia, hypoesthesia, or poorly localized deep muscular pain may also be present.

Classically, the presentation of acute compartment syndrome has been remembered by "The Five P’s": pulselessness, paresthesia, poikilothermia, paralysis, and pallor. However, aside from paresthesia, which may occur earlier in the course of the condition, these are typically late findings. Beware that the presence or absence of a palpable arterial pulse may not accurately indicate relative tissue pressure or predict the risk for compartment syndrome. In some patients, a pulse is still present, even in a severely compromised extremity. 

Physical exam should focus on the neurovascular territory of the involved compartment:

  • Observe skin, noting lesions, swelling or color change
  • Palpate over the compartment, observing temperature, tension, tenderness
  • Check pulses
  • Evaluate two-point discrimination and sensation
  • Evaluate motor function

Although the clinical features discussed above can help identify compartment syndrome, they have limited sensitivity and specificity. Other factors, such as compartment pressures, can be helpful in making the diagnosis.

Due to the potential for rapid progression of compartment syndrome, clinicians should perform serial exams. 

Evaluation

  • Radiographs should be obtained if a fracture is suspected
  • Measurement of intracompartmental pressure is not required but can aid in diagnosis if uncertainty exists. Compartment pressures are often measured with a manometer, a device that detects intracompartmental pressure by measuring the resistance that is present when a saline solution is injected into the compartment. Another method employs a slit catheter, whereby a catheter is placed within the compartment, and the pressure measured with an arterial line transducer. The slit catheter method is more accurate and allows for continuous monitoring. Its use is also recommended to measure all the surrounding compartments.
    • The normal pressure within the compartment is between 0 mmHg to 8 mmHg.
    • An intra-compartmental pressure greater than 30 mmHg indicates compartment syndrome and a need for fasciotomy.
      • When intra-compartmental pressure increases to within 10 mmHg to 30 mmHg of the patient's diastolic blood pressure, this indicates inadequate perfusion and relative ischemia of the involved extremity.
    • The perfusion pressure of a compartment, also known as the compartment delta pressure, is defined as the difference between the diastolic blood pressure and the intra-compartmental pressure:
      • delta pressure = diastolic pressure - measured intracompartmental pressure
      • clinicians often utilize delta pressure less than or equal to 30 mmHg as indicative of the need for fasciotomy.
  • Ultrasound with Doppler can be used to look for occlusion or thrombus.
  • Elevations in creatine phosphokinase (CPK) may suggest muscle breakdown from ischemia, damage, or rhabdomyolysis.
    • If rhabdomyolysis is being considered, renal function testing, urine myoglobin, and urinalysis should be tested.
    • If rhabdomyolysis is diagnosed, a chemistry panel is needed.
  • Preoperative studies should, at a minimum, include a complete blood count and coagulation studies.

Treatment / Management

  • Immediate surgical consult
  • Provide supplemental oxygen.
  • Remove any restrictive casts, dressings or bandages to relieve pressure.
  • Keep the extremity at the level of the heart to prevent hypo-perfusion.
  • Prevent hypotension and provide blood pressure support in patients with hypotension.
  • If ICP greater than or equal to 30 mmHg or delta pressure less than or equal to 30mmHg, fasciotomy should be done.

For patients who do not meet diagnostic criteria for acute compartment syndrome but who are at high risk based on history and physical exam findings, or for patients with intracompartmental pressures between 15-20 mmHg, serial intracompartmental pressure measurements are recommended. Patients with ICPs between 20-30 mmHg should be admitted and the surgical team should be consulted. For patients with intracompartmental pressures greater than 30 mmHg or delta pressures less than 30 mmHg, surgical fasciotomy should be done.

Acute compartment syndrome is a surgical emergency, so prompt diagnosis and treatment are critical. Once the diagnosis is confirmed, immediate surgical fasciotomy is needed to reduce the intracompartmental pressure. The ideal timeframe for fasciotomy is within six hours of injury, and fasciotomy is not recommended after 36 hours following injury. When tissue pressure remains elevated for that amount of time, irreversible damage may occur, and fasciotomy may not be beneficial in this situation.

If necrosis occurs before fasciotomy is performed, there is a high likelihood of infection which may require amputation. If infection occurs, debridement is necessary to prevent the systemic spread or other complications.

After a fasciotomy is performed and swelling dissipates, a skin graft is commonly used for incision closure. Patients must be closely monitored for complications which include infection, acute renal failure, and rhabdomyolysis.

Differential Diagnosis

  • Deep vein thrombosis
  • Cellulitis
  • Gas gangrene
  • Phlegmasia cerulean dolens
  • Rhabdomyolysis

Prognosis

  • The prognosis after treatment of compartment syndrome depends mainly on how quickly the condition is diagnosed and treated:

    • When fasciotomy is done within 6 hours, there is almost 100% recovery of limb function.

    • After 6 hours, there may be residual nerve damage. Data show that when the fasciotomy is done within 12 hours, only 2/3rd of patients have normal limb function.

  • In very delayed cases, the limb may require an amputation. 

  • Outcomes for the posterior compartment syndrome of the leg are worse than outcomes for the anterior compartment of the leg, since it is difficult to perform inadequate decompression of the posterior compartment.

  • Long-term studies on survivors do reveal residual pain, Volkmann contracture, mild neurological deficits and marked cosmetic defects in the affected extremity.

  • Recurrent compartment syndrome has been known to occur in athletes due to scarring.

  • There are some individuals who may die from acute compartment syndrome. Often these cases are caused by infection, which ultimately leads to sepsis and multiorgan failure.

Complications

  • Pain
  • Contractures
  • Rhabdomyolysis
  • Nerve damage and associated numbness and/or weakness
  • Infection
  • Renal failure
  • Death

Postoperative and Rehabilitation Care

  • Physical therapy to regain function and strength and prevent contractures and stiffness.
  • Wound care and monitoring for any ischemia, infection, gangrene.
  • Antibiotics if infection if warranted 
  • Pain medicine 
  • The patient will need to learn how to use an ambulatory device like crutches until healing is complete.
  • An occupational therapy consult is recommended to help teach the patient how to perform daily living activities.

Consultations

  • Orthopedic or surgical consultation
  • Infectious disease, if needed
  • Wound care, if needed
  • Physical therapy, if needed
  • Occupational therapy, if needed

Deterrence and Patient Education

Patients should be educated to seek care after traumatic injury or if they develop pain or swelling of an extremity. 

Pearls and Other Issues

When applying plaster casts, especially following reduction, uni-valving or bi-valving can help to reduce the pressure by about 50%. Beware that once the initial swelling dissipates, the cast can become excessively loose, which can decrease the amount of reduction accomplished.

Enhancing Healthcare Team Outcomes

The management of acute compartment syndrome requires a well-integrated interprofessional team of healthcare professionals including nurses, laboratory technologists, pharmacists and multiple physicians in different specialties. Without proper management, acute compartment syndrome can lead to high morbidity and poor outcomes. 

After surgery, an interprofessional team that provides a holistic approach can help achieve the best possible outcomes for patients. This may include the surgery or orthopedics team, nurses, physical therapists, occupational therapists, pharmacists, and social workers.


References

[1] Osier C,Smith C,Stinner D,Rivera J,Possley D,Finnan R,Bode K,Stockinger Z, Orthopedic Trauma: Extremity Fractures. Military medicine. 2018 Sep 1     [PubMed PMID: 30189079]
[2] Gordon WT,Talbot M,Shero JC,Osier CJ,Johnson AE,Balsamo LH,Stockinger ZT, Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds. Military medicine. 2018 Sep 1     [PubMed PMID: 30189076]
[3] Rickert KD,Hosseinzadeh P,Edmonds EW, What's New in Pediatric Orthopaedic Trauma: The Lower Extremity. Journal of pediatric orthopedics. 2018 Sep     [PubMed PMID: 29975292]
[4] DeLee JC,Stiehl JB, Open tibia fracture with compartment syndrome. Clinical orthopaedics and related research. 1981 Oct;     [PubMed PMID: 7026116]
[5] Elliott KG,Johnstone AJ, Diagnosing acute compartment syndrome. The Journal of bone and joint surgery. British volume. 2003 Jul;     [PubMed PMID: 12892179]
[6] Brandão RA,St John JM,Langan TM,Schneekloth BJ,Burns PR, Acute Compartment Syndrome of the Foot Due To Frostbite: Literature Review and Case Report. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2018 Mar - Apr     [PubMed PMID: 29478482]
[7] Liu B,Barrazueta G,Ruchelsman DE, Chronic Exertional Compartment Syndrome in Athletes. The Journal of hand surgery. 2017 Nov     [PubMed PMID: 29101975]
[8] Oliver JD, Acute Traumatic Compartment Syndrome of the Forearm: Literature Review and Unfavorable Outcomes Risk Analysis of Fasciotomy Treatment. Plastic surgical nursing : official journal of the American Society of Plastic and Reconstructive Surgical Nurses. 2019 Jan/Mar;     [PubMed PMID: 30801492]
[9] Patel RV,Haddad FS, Compartment syndromes. British journal of hospital medicine (London, England : 2005). 2005 Oct;     [PubMed PMID: 16255266]
[10] McQueen MM,Gaston P,Court-Brown CM, Acute compartment syndrome. Who is at risk? The Journal of bone and joint surgery. British volume. 2000 Mar;     [PubMed PMID: 10755426]
[11] Park S,Ahn J,Gee AO,Kuntz AF,Esterhai JL, Compartment syndrome in tibial fractures. Journal of orthopaedic trauma. 2009 Aug;     [PubMed PMID: 19633461]
[12] Schmidt AH, Acute compartment syndrome. Injury. 2017 Jun;     [PubMed PMID: 28449851]
[13] Smith-Singares E,Boachie JA,Iglesias IM,Jaffe L,Goldkind A,Jeng EI, Fusobacterium emphysematous pyomyositis with necrotizing fasciitis of the leg presenting as compartment syndrome: a case report. Journal of medical case reports. 2017 Nov 28     [PubMed PMID: 29179775]
[14] Thabet AM,Simson JE,Gerzina C,Dabash S,Adler A,Abdelgawad AA, The impact of acute compartment syndrome on the outcome of tibia plateau fracture. European journal of orthopaedic surgery     [PubMed PMID: 28785833]
[15] Dunphy L,Morhij R,Tucker S, Rhabdomyolysis-induced compartment syndrome secondary to atorvastatin and strenuous exercise. BMJ case reports. 2017 Mar 16     [PubMed PMID: 28302660]
[16] Cone J,Inaba K, Lower extremity compartment syndrome. Trauma surgery     [PubMed PMID: 29766095]
[17] Mansfield CJ,Bleacher J,Tadak P,Briggs MS, Differential examination, diagnosis and management for tingling in toes: fellow's case problem. The Journal of manual     [PubMed PMID: 29449772]
[18] Bloch A,Tomaschett C,Jakob SM,Schwinghammer A,Schmid T, Compression sonography for non-invasive measurement of lower leg compartment pressure in an animal model. Injury. 2018 Mar     [PubMed PMID: 29195681]
[19] Wesslén C,Wahlgren CM, Contemporary Management and Outcome After Lower Extremity Fasciotomy in Non-Trauma-Related Vascular Surgery. Vascular and endovascular surgery. 2018 Jan 1     [PubMed PMID: 29716475]
[20] McQueen MM,Duckworth AD, The diagnosis of acute compartment syndrome: a review. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2014 Oct;     [PubMed PMID: 26814506]
[21] Tam JPH,Gibson AGF,Murray JRD,Hassaballa M, Fasciotomy for chronic exertional compartment syndrome of the leg: clinical outcome in a large retrospective cohort. European journal of orthopaedic surgery     [PubMed PMID: 30145669]
[22] Maher JM,Brook EM,Chiodo C,Smith J,Bluman EM,Matzkin EG, Patient-Reported Outcomes Following Fasciotomy for Chronic Exertional Compartment Syndrome. Foot     [PubMed PMID: 29931999]
[23] Fouasson-Chailloux A,Menu P,Dauty M, Evaluation of Strength Recovery after Traumatic Acute Compartment Syndrome of the Thigh. A Case Study. Ortopedia, traumatologia, rehabilitacja. 2017 Aug 31     [PubMed PMID: 29086744]
[24] Meulekamp MZ,Sauter W,Buitenhuis M,Mert A,van der Wurff P, Short-Term Results of a Rehabilitation Program for Service Members With Lower Leg Pain and the Evaluation of Patient Characteristics. Military medicine. 2016 Sep     [PubMed PMID: 27612357]
[25] Campano D,Robaina JA,Kusnezov N,Dunn JC,Waterman BR, Surgical Management for Chronic Exertional Compartment Syndrome of the Leg: A Systematic Review of the Literature. Arthroscopy : the journal of arthroscopic     [PubMed PMID: 27020462]