Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Compartment Syndrome

Basics
Description

  • Increase in tissue pressure within a limited space, compromising circulation and function of the contents of the space.
  • Acute compartment syndrome is a limb-threatening emergency.
  • Chronic (or exercise-induced or exertional) compartment syndrome usually is a self-limited symptomatic disorder.
  • The elevated tissue pressure causes decreased perfusion, which can lead to necrosis of tissues and nerves within the enclosed space, with resulting ischemic contracture, paresis, numbness, or loss of the involved limb.
  • Depending on the amount of muscle death (rhabdomyolysis), myoglobinuria, acute tubular necrosis, hyperkalemia, and kidney failure can occur.
General Prevention
  • A high index of suspicion is needed, especially in dealing with patients with obtunded sensorium because of trauma or pharmacologic agents, or in children in whom the history and physical examinations often are unreliable.
  • Although most cases involve the legs and forearms, compartment syndromes in the thigh, hand, foot, arm, and buttock are well recognized.
Epidemiology
Incidence
  • 1-5% of all tibia fractures
  • 0.25% of distal radius fractures
  • 3% of forearm fracture
  • Up to 10% of displaced calcaneus fractures
Risk Factors
  • Trauma, especially high-energy trauma
  • Crush injury
  • Prolonged unconsciousness (dependant position)
    • Anesthesia
    • Drug overdose
  • Decreased mental status
  • Young adult males with tibia or forearm fractures
  • Displaced pediatric supracondylar humerus fractures
  • Long surgical procedures
  • Fractures or osteotomies
  • Ischemic injuries, especially after reperfusion
  • Soft-tissue trauma: Crush, contusion, snake bite
  • Casts, dressings
  • Tight surgical closures
  • Burns
  • Infiltration of intravenous fluids
  • Intracompartmental hemorrhage
  • Antishock trousers
  • Intraosseous infusion in neonates
Pathophysiology
Local blood flow does not meet metabolic demand of tissues, leading to necrosis.
 
Etiology
  • Can result from any cause of increased intracompartmental pressures
  • External compression from:
    • Casts
    • Positioning
  • Hemorrhage from:
    • Fractures:
      • After manipulation
      • Open or closed
    • Arterial or venous injury
    • Blunt trauma
  • Crush injury leading to muscle bleeding, massive cell death, and subsequent extravasation of cytoplasmic fluid
  • Reperfusion injury after vascular repair
  • Iatrogenic (see Risk Factors)
Associated Conditions
  • Coagulopathy
  • Altered mental state
Diagnosis
Signs and Symptoms
  • Classically, the 5 P’s (pain, pallor, paresthesia, paralysis, and pulselessness)
  • A high index of suspicion is necessary.
  • Clinical signs in children and obtunded patients are not reliable.
History
  • Pain out of proportion to injury:
    • Increase in need for pain medication
    • Once nerves die, pain may not be present.
    • Absence of pain in the presence of compartment syndrome is a late finding and a poor prognostic indicator.
  • Numbness or tingling (paresthesias)
Physical Exam
  • Note mental status.
  • Assess vital signs, especially diastolic blood pressure.
  • Perform motor examination.
  • Perform sensory examination.
    • Hand compartment syndrome has no loss of sensation because the nerves are subcutaneous.
  • Assess tenseness of compartment.
    • Compartments may be palpably tense.
    • Tenseness of the deep compartment of the leg is difficult to assess.
  • Note pain with passive stretch of the muscles traversing the compartment.
  • Assess for asymmetry of pulses (pulselessness is late finding).
Tests
  • Measurement of compartment pressures
  • Sterile procedure:
    • Leg: Anterior, lateral, and superficial and deep posterior compartments
    • Thigh: Anterior, posterior, medial
    • Hand: Thenar, hypothenar, interossei, adductor pollicis, carpal tunnel
    • Foot: Lateral, medial, central, intrinsic
    • Forearm: Volar, dorsal, mobile wad
    • Fingers: Clinical examination
    • Arm: Anterior and posterior, deltoid muscle
    • Buttock: Gluteus maximus
  • Compartment pressure of 40 mm Hg or within 30 mm Hg of the diastolic pressure requires surgical compartment decompression.
  • Recheck every few hours if needed.
  • Check near fracture.
  • Chronic compartment syndrome shows increased tissue pressure at rest and/or prolonged elevation of pressure after exercise.
Lab
  • Basic metabolic panel/Chem 7
    • Look for hyperkalemia from muscle death.
  • Serial creatine phosphokinase if the clinician suspects substantial muscle death
  • Urine for myoglobin
  • Hematocrit to monitor blood loss into thigh
  • Routine preoperative laboratory tests
Imaging
Routine radiographs to evaluate skeletal trauma
 
Pathological Findings
  • Bulging muscle through fasciotomy
  • Tissue necrosis if diagnosis is delayed
Differential Diagnosis
  • Arterial occlusion (also characterized by pain and pallor):
    • Pulselessness
    • No immediate increase in compartment pressure.
  • Neurapraxia (no increase in pressure or tenseness)
Treatment
General Measures
  • Patients suspected of developing a compartment syndrome should have the compartment pressure monitored.
  • Immediate splitting or removal of a cast or tight dressing
  • For patients under surveillance for a suspected developing compartment syndrome, place limb at the level of the heart.
  • Compartment syndrome is a surgical emergency requiring surgical decompression or fasciotomy to avoid additional complications.
Activity
Bed rest if a compartment syndrome is suspected
 
Nursing
Frequent neurovascular checks
 
Special Therapy
Physical Therapy
Postoperative physical therapy varies, depending on soft-tissue and bony injury.
 
Medication (Drugs)
First Line
  • Consider alkalizing urine and giving fluids to minimize renal damage if myoglobinuria is present.
  • Treat hyperkalemia, if present.
Second Line
  • May require treatment for underlying cause of compartment syndrome:
    • Anticoagulation for DVT
    • Antibiotics for open fracture
Surgery
  • In general, fascial tissues enveloping the affected compartment are opened in a longitudinal fashion, thereby decompressing the enclosed space and allowing tissue expansion and better perfusion.
  • The wound then is left open, and delayed primary closure or skin grafting is done at a later date.
  • Postoperative dressings can be moistened gauze or vacuum-assisted closure dressings.
  • During the immediate postoperative period, the involved limb should be elevated to minimize swelling.
  • Leg:
    • 1 lateral (for the anterior and lateral compartment) and 1 medial (for the deep and superficial posterior compartments) skin incision
  • Thigh:
    • 1 lateral skin incision
    • Release the anterior compartment.
    • Release the posterior compartment if needed through the same incision.
    • Use a medial skin incision for the medial compartment as necessary.
  • Hand:
    • 2 dorsal incisions, over the 2nd and 4th metacarpals
    • 2 palmar incisions, 1 over the thenar compartment, and 1 for carpal tunnel.
    • 1 incision for hypothenar compartment as needed
  • Forearm:
    • Release the volar compartment with lazy-S incision.
    • This incision can be extended to release the carpal tunnel.
    • Can release dorsally, but usually not necessary
  • Foot:
    • Release with medial incision.
    • Add 2 dorsal incisions as necessary, over the 2nd and 4th metatarsals.
  • Arm:
    • Medial incision, especially if exploration of vessels is necessary
  • Fingers:
    • Release ulnarly for the 2nd and 3rd digits, radially for the 4th and 5th digits.
  • Gluteus:
    • Release with 1 incision over the gluteus maximus.
Follow-up
Disposition
Issues for Referral
  • Prosthetic referral for limb loss
  • Referral for orthotic splints such as ankle-foot orthosis for foot drop
  • Occupational therapy for treatment of hand weakness, specialized splints
  • Physical therapy for regaining strength and mobility
  • Plastic surgery for wound issues
Prognosis
  • In general, complications can be minimized with rapid diagnosis and fasciotomy.
  • Fasciotomies are not benign procedures.
    • They can leave large, painful scars, especially if they cannot be closed primarily.
    • Chronic venous stasis can develop .
  • Paresis does not usually improve.
  • Numbness usually does not improve.
Complications
  • Motor deficit:
    • Weakness or paresis
    • Foot drop
    • Volkmann contracture
  • Sensory deficits:
    • Complications, such as ulcers, infections, and burns, secondary to an insensate limb
  • Kidney failure from rhabdomyolysis
  • Infection from fasciotomy with necrotic muscle
  • Chronic venous stasis
  • Loss of limb
  • Reflex sympathetic dystrophy
Patient Monitoring
  • Intraoperatively, compartment pressure can be measured after fasciotomy to confirm that the compartment has been decompressed appropriately.
  • After closure, monitoring for redevelopment of compartment syndrome is important.
Miscellaneous
Codes
ICD9-CM
958.8 Compartment syndrome
 
Patient Teaching
  • The patient must be informed about the need for subsequent delayed primary closure or skin grafting.
  • Inform the patient of the risk for weakness, numbness, and loss of limb.
  • For high-risk orthopaedic procedures, such as tibial nailing and high tibial osteotomy, patients must be advised of the risk of compartment syndrome and the possible need for fasciotomy.
Activity
Activity depends on the underlying injury.
 
Prevention
  • Repositioning patients during long procedures in the operating room
  • Care with applying casts and dressings
  • Monitoring fluid extravasation with arthroscopy or pulsatile lavage
  • High index of suspicion
FAQ
Q: How can you have tissue ischemia with palpable pulses?
A: The elevated tissue pressure causes an increase in venous pressure. The capillary bed blood flow loses its flow gradient, and flow through the capillary bed can decrease to the point where it does not meet metabolic demand. Arterial pressure usually is greater than the elevated tissue pressure; flow is maintained through the compartment and can be felt as a pulse.
 
Q: Can compartment syndrome develop with an open fracture?
A: Yes. Open fractures alone do not decompress a compartment and are often high-energy, crushing-type injuries.

Q: What is the most common symptom of compartment syndrome?
A: Pain out of proportion to the injury.

Comments are closed.