Compartment syndrome

Compartment syndrome
Classification and external resources
Fasciotomy, covered with a skin graft.
ICD-10	M62.2, T79.6
ICD-9	729.7, 958.9
DiseasesDB	3028
MedlinePlus	001224
eMedicine	emerg/739
MeSH	D003161

Compartment syndrome is a limb threatening and life threatening condition, defined as the compression of nerves, blood vessels, and muscle inside a closed space (compartment) within the body ^[1]. This leads to tissue death from lack of oxygenation due to the blood vessels being compressed by the raised pressure within the compartment. Compartment syndrome most often involves the forearm and lower leg, ^[2] and can be divided into acute, subacute, and chronic compartment syndrome. An alternative definition of compartment syndrome, according to Rankin, is characterized by pressure within a closed space thus compromising the circulation and function of tissues in that space (Rankin, 1981).

Causes

Because the connective tissue 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.^[3][4] Another possible cause can be the use of creatine monohydrate; a history of creatine use has been linked to this condition.^[5][6] Compartment syndrome can also occur following surgery in the Lloyd Davis 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 (e.g. Flowtron boot) 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 (CCS).^[7][8] This is usually not an emergency, but the loss of circulation can cause temporary or permanent damage to nearby nerves and muscles. One cause of compartment syndrome is through exercise called Chronic Exertional Compartment Syndrome. According to Touliopolous, CECC 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 (Touliopolous, 1999) When this happens pressure builds up in the tissues and muscles causing tissue ischemia (Touliopolous, 1999). The cause of compartment syndrome is due to excess pressure on 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.

Pathophysiology

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 (due to increased blood flow due to trauma or excessive exercise) 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.

Symptoms and signs

There are classically 5 "Ps" associated with compartment syndrome — pain out of proportion to what is expected, paresthesia, pallor, paralysis, pulselessness; sometimes a 6th P, for polar/poikilothermia (failure to thermoregulate) is added. Of these, only the first two are reliable in the diagnosis of compartment syndrome.^[9][10] Paresthesia, however, is a late symptom. Some symptoms of compartment syndrome are paresthesia, palpable pulse, paresis and pallor. 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 (Shears, 2006). The other three symptoms of compartment syndrome are palpable pulse, paresis and pallor. These symptoms are irreversible and consistent during compartment syndrome and its part of the diagnosis (Shears, 2006).

• Pain is often reported early and almost universally. The description is usually of severe, deep, constant, and poorly localized pain, sometimes described as out of proportion with the injury. The pain is aggravated by stretching the muscle group within the compartment and is not relieved by analgesia up to and including morphine.
• Paresthesia (altered sensation e.g. "pins & needles") 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 (pressure). 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.
• Note that 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.

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^[10] as an indication for fasciotomy while others suggest a <30 mmHg difference between intracompartmental pressure and diastolic blood pressure.^[11] 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 (with a simple intravenous catheter and needle) 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.^[12]

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.^[13] 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 (Rorabeck, 1984). It usually occurs in the upper or lower limb after an injury. During compartment syndrome there is decreased pressure due to the accumulation of necrotic debris and haemorrhage, especially haemorrhage to secondary fractures (Rorabeck, 1984). Acute compartment syndrome (ACS) of the lower extremity is a clinical condition that is seen fairly regularly in modern practice (Shagdan, 2010). Although pathophysiology of the disorder is well known to physicians who care for patients with musculoskeletal injuries, the diagnosis is often difficult to make (Shagdan, 2010). If left untreated, acute compartment syndrome can lead to more severe conditions including rhabdomyolysis and kidney failure potentially leading to death.

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.^[14] 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.^[15][16] The main treatment for compartment syndrome is surgery. There needs to be an incision in the skin so that the skin may be retracted back. 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.

Technology solutions for compartment syndrome involving continuous monitoring have also been proposed and tested. ^[17]

Complications

Failure to relieve the pressure can result in necrosis of tissue in that compartment, since capillary perfusion will fall leading to increasing hypoxia 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 (Shears, 2006).

See also

• Volkmann's contracture
• Abdominal compartment syndrome

References

1. ^ http://emedicine.medscape.com/article/828456-overview
2. ^ Medline Plus. URL: http://www.nlm.nih.gov/medlineplus/ency/article/001224.htm Accessed 23 December 2009
3. ^ Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ (December 2007). "Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective". Am Surg 73 (12): 1199–209. PMID 18186372. 
4. ^ Maerz L, Kaplan LJ (April 2008). "Abdominal compartment syndrome". Crit. Care Med. 36 (4 Suppl): S212–5. doi:10.1097/CCM.0b013e318168e333. PMID 18382196. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/CCM.0b013e318168e333. 
5. ^ Potteiger JA, Carper MJ, Randall JC, Magee LJ, Jacobsen DJ, Hulver MW (June 2002). "Changes in Lower Leg Anterior Compartment Pressure Before, During, and After Creatine Supplementation" (PDF). J Athl Train 37 (2): 157–163. PMC 164339. PMID 12937429. http://www.nata.org/jat/readers/archives/36.1/i1062-6050-036-01-0085.pdf. 
6. ^ Hile AM, Anderson JM, Fiala KA, Stevenson JH, Casa DJ, Maresh CM (2006). "Creatine supplementation and anterior compartment pressure during exercise in the heat in dehydrated men". J Athl Train 41 (1): 30–5. PMC 1421498. PMID 16619092. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1421498. 
7. ^ Wanich T, Hodgkins C, Columbier JA, Muraski E, Kennedy JG (December 2007). "Cycling injuries of the lower extremity". J Am Acad Orthop Surg 15 (12): 748–56. PMID 18063715. http://www.jaaos.org/cgi/pmidlookup?view=long&pmid=18063715. 
8. ^ Verleisdonk EJ (October 2002). "The exertional compartment syndrome: A review of the literature". Ortop Traumatol Rehabil 4 (5): 626–31. PMID 17992173. 
9. ^ "Compartment Syndrome: Fractures, Dislocations, and Sprains: Merck Manual Professional". http://www.merck.com/mmpe/sec21/ch309/ch309c.html. 
10. ^ ^{a b} "emedicine: compartment syndrome". http://www.emedicine.com/EMERG/topic739.htm. 
11. ^ Pocketbook of Orthopaedics and Fractures: Ronald McRae
12. ^ Blackman PG (March 2000). "A review of chronic exertional compartment syndrome in the lower leg". Med Sci Sports Exerc 32 (3 Suppl): S4–10. PMID 10730989. 
13. ^ Salcido R, Lepre SJ (October 2007). "Compartment syndrome: wound care considerations". Adv Skin Wound Care 20 (10): 559–65; quiz 566–7. doi:10.1097/01.ASW.0000294758.82178.45. PMID 17906430. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?an=00129334-200710000-00009. 
14. ^ Meyer RS, White K, Smith J, Groppo E, Mubarak S, Hargens A (October 2002). "Intramuscular and blood pressures in legs positioned in the hemilithotomy position". J Bone and Joint Surgery 84-A (10): 1829–35. 
15. ^ Undersea and Hyperbaric Medical Society. "Crush Injury, Compartment syndrome, and other Acute Traumatic Ischemias". http://www.uhms.org/ResourceLibrary/Indications/CrushInjury/tabid/274/Default.aspx. 
16. ^ Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P (August 1996). "Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial". J Trauma 41 (2): 333–9. PMID 8760546. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0022-5282&volume=41&issue=2&spage=333. 
17. ^ http://www.healthtechzone.com/channels/medical-software/articles/175767-cell-phone-monitoring-kit-surgery-patients-announced-investors.htm

Further reading

• 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 (supp): 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., (2003, June). 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. (1981, December). Anterior tibial compartmental syndrome: an unusual presentation. Journal of the National Medical Association, 73.
• Rorabeck, C.H., (1984, January). The treatment of compartment syndromes of the leg. Journal of Bone and Joint Surgery-British, 66-B. Retrieved from http://web.jbjs.org.uk/cgi/content/abstract/66-B/1/93
• Shadgan, B., et. al. (2010, October). Current thinking about acute compartment syndrome of the lower extremity, Canadian Journal of Surgery, 53.
• Shears, E., Porter, K. (2006). Acute compartment syndrome of the limb. Trauma, 8.
• Touliopolous, S., Hershman, E.B., (1999, March). Lower leg pain: diagnosis and treatment of compartment syndromes and other pain syndromes of the leg. Sports Medicine, 27.

External links

• Chronic Exertional Compartment Syndrome detailed at MayoClinic.com
• Duke Orthopedics compartment_syndrome
• 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