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