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Compartment Syndrome Etiology, Diagnosis and Management

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List of Contents

  • Introduction
  • Aetiology
  • Pathophysiology
  • Clinical Features & Diagnosis
  • Management
  • Chronic Compartment Syndrom
  • Conclusion
  • References

Introduction

Compartment syndrome defined as an elevation of interstitial pressure inside a closed osseofascial compartment; this will result in small blood vessels compromise, and this will end up permanent damage to the contents of the space if this situation continues for a particular duration without decompression. (1)(2)

Compartment syndromes usually categorized into acute and chronic, depending on the aetiology of the increased pressure and the duration of symptoms. (3)

It is usually present as a complication of trauma or other conditions that lead to alteration in the perfusion to an extremity, mostly follows a fracture or a crush injury to the extremity. (3)

The resulting compromise in the blood supply, which causes necrosis that may involve not only the muscle and nerves but also even the skin, causing blisters and ulcers. Ultimately, there is replacement with fibrous tissue that results in contractures. (2)

The anatomical sites that may develop compartment syndrome are:

  1. Compartments of the legs (Anterior and deep posterior tibial syndromes).
  2. Compartments of the forearm (Deep forearm syndrome and Compression ischemia).
  3. It can be found anywhere skeletal muscle is surrounded by semi-rigid fascia such as in Buttocks, shoulder, hand, foot, arm, and lumbar paraspinal muscles, which are relatively rare sites. (1)(2)

Although the existence of compartment syndrome is well known and most clinicians are familiar with its pathophysiology and understand its potential limb-threatening nature, the

essential problem is there is no clear definition of when compartment syndrome is present. (4)  

Aetiology

The increased pressure within a closed space may cause obliteration of the small vasculature resulting in gangrene in severe cases and tissue necrosis in mild cases when the pressure is enough to obliterate only the microvessels of this space, and this increased pressure can be due to many causes. Table (Table1) shows the commonly used classification of the causes of increased pressure within the compartment leading to compartment syndrome.

Reduction in Compartment Size

 

 

 

  • Surgical repairs of fascial defects, e.g., muscle hernias.
  • Tight dressing and splinting (causes a typical syndrome of “compression ischemia”)
  • Localized external pressure
  • Burn injuries.
Expansion in Compartment Content
  • Bleeding (e.g., Major vascular injury and Bleeding disorders)
  • Increased capillary permeability (e.g., Postischemic swelling, Trauma, Burns and Orthopedic procedures)
  •  Increased capillary pressure (e.g., Exercise)
  • Muscle hypertrophy
  • Infiltrated infusion
  • Nephrotic syndrome
  • Leukemic infiltration
  • Viral myositis
  • Acute hematogenous osteomyelitis
  • Diabetes
  • Hypothyroidism
  • Crush syndrome
  • Ruptured ganglia and cyst
  • Snakebite
  • Popliteal cyst. (2)

(Table 1)

Pathophysiology 

A wide range of causes (e.g., inflammation or Bleeding) may raise the pressure within one of the osteofascial compartments; this ends up in diminished capillary flow which leads to muscle ischemia, further oedema, and more significant pressure inside the compartment and yet more severe ischemia – a vicious circle that results, after 12 hours or less, in necrosis of nerve and muscle inside the compartment. This vicious circle is displayed in Figure (1). (5)

 

  Compartment Syndrome Etiology, Diagnosis and Management

 

Figure (1): This figure shows the cycle of events that lead to the development of compartment syndrome. (6)

Clinical Features & Diagnosis

The classical signs and symptoms of ischemia, usually present in compartment syndrome, are the “5p’s” as follows: –

  • Pain, more significant than expected.
  • Pallor of the limb.
  • Pulses are absent.
  • Paralysis of the limb.

Pain is severe and out of proportion to the injury or surgery and usually described as burning, deep in nature, it is not relieved by painkillers and morphine, and it is worsened by the passive stretch of compartment muscles (passive extension become extremely painful).

The diagnosis of compartment syndrome is based on clinical assessment and intracompartmental pressure measurement. (2)(3) The earliest of the ‘classic’ features are pain, altered sensibility, and weakness of active muscle contraction, and they are good indicators for initial diagnosis. The sensation of skin should be carefully and regularly checked. (5) Paresis/paralysis are late features that may indicate both nerve and muscular lesions. The absence of pulse is not a diagnostic criteria because peripheral pulses are usually present when a high compartment pressure is diagnosed. (7)(3)

The “5p’s” may occur in patients without compartment syndrome, it is also not useful in patients with a decreased level of consciousness, unconscious, or insensate who are unable to provide feedback (only helpful in an alert patient). 

The confirmation of the diagnosis is often made by measuring the intracompartmental pressures; it is essential for early diagnosis that some surgeons advocate the utilization of continuous intracompartmental pressure monitoring for high-risk injuries and especially in leg or forearm fractures in unconscious patients. A split catheter is introduced into the compartment, and therefore the pressure is measured near the level of the fracture. A differential pressure (also called perfusion pressure or “Delta-P”)– the difference between the general diastolic pressure and the compartment pressure – of less than 30 mmHg (4.00 kP) is an indication for immediate compartment decompression (significant of compartment syndrome). (5)

technique used for the determination of tissue pressure

Figure (2) This technique used for the determination of tissue pressure. (A) Tissue pressure is measured by identifying the amount of pressure within closed space required to overcome the pressure within a closed compartment and inject a small amount of saline. (B) Use of wick catheter for monitoring compartment pressures. (3)

Management

The endangered compartment (or compartments) must be immediately decompressed. Immediate management involves the identification and removal of external compressive forces and complete removal of any casts or dressings overlying the limb. After removing the cast, the patient should be carefully examined, and the limb should not be elevated but maintained at heart level to perfuse the compartment (elevation lead to further decrease in end-capillary pressure and worsen the ischemia of the muscle).

If the clinical condition does not improve, fasciotomy is should be done as an emergency procedure to decompress the compartments and avoid irreversible ischemic changes. (5)(7)

Emergency fasciotomy is indicated in normotensive patients with positive clinical findings and with ΔP of 30 mmHg or below, in uncooperative or unconscious patients ΔP greater than 30 mmHg, and in hypotensive patients with ΔP higher than 20 mmHg. (7)

When the ischemia is localized to a single compartment like the anterior tibial, it may be approached directly. If the limb is involved as a whole as often happens in trauma, the double incision technique (1 medial and 1 lateral). (2)

The principles of fasciotomy consist of adequate and extensile incision, a total release of all involved compartment, Preservation of the important structures, debridement, skin coverage usually after 7-10 days.

Post-operative pain: is usually a significant manifestation of compartment syndrome, and analgesia should be prescribed to ease the pain. The patient should be watched closely for possible complications, particularly rhabdomyolysis and acute renal failure. (6)

Fasciotomy: incisions should never be closed primarily. Left open and dressed and two days later, a second look procedure to ensure the viability of all muscle groups. The wound may be closed by delayed primary closure if possible, without tension or split skin grafting. (the delay will allow wound edges approximation at closing) and the wound edges need to be frequently irrigated and debrided before final closure. (2)(7)

There are multiple complications associated with fasciotomy:

  • Altered sensation within the wound margins (the most common).
  • Skin problems (dry skin, Pruritus, Discolored wounds)
  • Swollen limbs and Muscle herniation
  • Tethered scars and tendons
  • Wound Pain and Frequent ulceration
  • Chronic venous insufficiency.

Fasciotomy after 8 hours in cases of acute compartment syndrome is controversial. The myoneural damage is permanent at this stage, and the increased risks may outweigh any potential advantages. (2)

Complications of acute compartment syndrome:Delay in performing fasciotomy of more than 6 hours is probably going to cause (1) Muscle contractures (2) muscle weakness (3) sensory loss (4) infection (5) nonunion of fracture. In severe cases, amputation may be necessary because of infection or lack of function. (2)

Compartment Syndrome Etiology, Diagnosis and Management

Figure (3): Double incision fasciotomy used to decompress all four compartments adequately. (2)

Chronic Compartment Syndrome

Some athletes develop symptoms after exercise causing them to discontinue training and thus have a chronic manifestation of the syndrome

The patient usually presents as recurrent claudication during exertional activity and is relieved by rest. After exercise, the findings of localized pain (pretibial pain, in the anterior compartment of the leg), pain on passive motion, and occasionally temporary paresthesia and numbness are indicative.

Usually, the compartment pressure measurements while exercising on the treadmill (>30 mm Hg 1 minute after exercise or >20 mm Hg 5 minutes after exercise, or absolute values >15 mm Hg while resting are consistent with this diagnosis).

This syndrome may result from muscle hypertrophy within the tight osseofascial compartment. As the muscles hypertrophy and the amount of oedema within the compartment increases, the blood supply to the nerves and muscles within the involved compartment is reduced, and the pressure continues to rise.

Treatment consists of activity alteration, including the gradual onset of training. If not useful, compartment pressures may be measured while the patient is exercising on a treadmill, and if the pressures are elevated, surgical decompression is indicated. (1)(2)(3)(8)

Conclusion

Acute compartment syndrome is a surgical emergency, and a high level of suspicion is needed for diagnosis. Compartment pressure measurement may help in the diagnosis, with a delta pressure of 30 mmHg or below suggestive of acute compartment syndrome. The definitive treatment is immediate surgical decompression of the threatened compartment/s.  A delay of more than 6 hours usually associated with permanent myoneural damage, so timing is crucial. Chronic compartment syndrome is recurrent claudication during exertional activity found mostly in athletes.

References
  • (1) Ebenezer J, Ebnezar J. Textbook of orthopedics. 4th ed. St. Louis: Jaypee Brothers Medical Publishers; 2010.
  • (2) Kulkarni G. Textbook of orthopedics and trauma (4 volumes). 3rd ed. Jaypee Brothers Medical P; 2016.
  • (3) Campbell W, Canale S, Beaty J, Daugherty K, Jones L, Azar F et al. Campbell’s operative orthopaedics. 13th ed. Philadelphia: Elsevier; 2017.
  • (4) Bhandari M, Adili A. Evidence-based orthopedics. 1st ed. Chichester, West Sussex, U.K.: Wiley-Blackwell; 2012.
  • (5) Solomon L, Warwick D, Nayagam S. Apley and Solomon’s Concise System of Orthopaedics and Trauma, Fourth Edition. 4th ed. Hoboken: CRC Press; 2014.
  • (6) Donaldson J, Haddad B, Khan W. The Pathophysiology, Diagnosis and Current Management of Acute Compartment Syndrome. The Open Orthopaedics Journal. 2014;8(1):185-193.
  • (7) Via AG, Oliva F, Spoliti M, Maffulli N. Acute compartment syndrome. Muscles Ligaments Tendons J. 2015 Mar 27;5(1):18-22.
  • (8) Skinner H. CURRENT Diagnosis & Treatment in Orthopedics, Fifth Edition. 5th ed. Blacklick: McGraw-Hill Publishing; 2014.

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