Trauma
Compartment Syndrome
Background
- Definition(s)
- Acute condition caused by increased interstitial pressure within fascia surrounding the muscle
- Synopsis
- Differentiate from
- Chronic compartment syndrome (CCS):
- Characterized by pain resolving with discontinuation of exercise
- Not a medical emergency
- Crush injury
- Medical emergency
- Common in the legs
- Muscle ischemia > 6 hours carries significant morbidity
Pathophysiology
- Mechanism
- Increase in fascia interstitial pressure resulting in low vasculature pressure, leading to
- Local circulatory compromise
- Nerve injury
- Muscle necrosis
- Cellular destruction results in release of myoglobin and renal injury
- Etiology/Risk Factors
- Source(s)
- External compression
- Circumferential compression
- Increased volume within compartment
- Edema, hematoma, snake envenomation
- Risk Factors
- Long bone fractures (Tibial fracture)
- Burns
- Tight cast or bandage
- Vascular injury
- Crush injury
- Penetrating injury
- Anabolic steroid use
- Snake envenomation
- Ruptured Baker's cyst
- Surgical procedures with the use of compression stockings
- Epidemiology
- Incidence/Prevalence
- Tibial fracture account for about 2-12% of all compartment syndrome cases
- Incidence varies depending on the event cause
- Many patients may go undetected
- Mortality/Morbidity
- Decrease limb function: 30%
- Amputation: 20%
- Mortality: 15%
Diagnostics
- History/Symptoms
- Trauma
- Burns
- Prolonged compression of extremity
- Snake envenomation
- Physical Exam/Signs
- It is critical to perform regular serial exams
- Pain
- Out of proportion to injury
- Increase on passive flexion
- Paresthesia
- Paralysis, pallor, pulselessness
- Late signs
- Suggest irreversible tissue injury
- Palpable peripheral pulses do not rule-out ACS
- Labs/Tests
- Labs not usually required for diagnosis
- Monitor
- Vitals
- Urine output, pH and myoglobin
- Electrolytes
- Watch for hyperkalemia (highest 12-36 hour post injury)
- Osmolarity
- ABGs
- CPK
- Levels > 1,000 U/mL (confirms compartment syndrome)
- Serial measurements to monitor disease progression
- Pre-Op
CBC
- Coags
- CMP
- Electrolytes
- ESR, CRP (most likely elevated due to inflammation)
- Imaging
- X-ray/CT scan
- Evaluate fractures
- Not helpful for ACS diagnosis
- Ultrasound
- MRI
- T1: muscle damage
- Gadolinium-DTPA: edema
- Other Tests/Criteria
- Serial compartment pressures
- Gold standard
- Normal pressure: 0-8 mmHg
- 20-30 mmHg with symptoms
- > 30 mmHg
- Differential Diagnosis
Treatment
- Initial/Prep/Goals
- ABCs, monitors, oxygen at high rate
- Place extremity at level of heart
- Do not elevate higher due to risk of decreased perfusion
- Prevent hypotension and provide blood pressure support in patients with hypotension
- If ICP ≥ 30 mmHg or delta pressure ≤ 30 mmHg: perform fasciotomy
- If > 20 mmHg with symptoms: surgical consult and probable fasciotomy
- To relieve pressure remove any
- Restrictive casts
- Dressings
- Bandages
- Medical/Pharmaceutical
- Analgesics
- Mannitol
- Reduces compartment pressure
- Renal protection / rhabdomyolysis
- Keep urine output at 1-2 mL/kg/hr
- Continuous crystalloids: 500 mL/hour IV
- If blood pH > 7.45
- Antibiotics (fasciotomy)
- Surgical/Procedural
- Hyperbaric oxygen
- Promotes tissue survival by causing vasoconstriction and reduction of edema
- Remove casts / bandages
- Remove completely
- Partial removal reduces compartment pressure by only 50%
- Fasciotomy (View Video)
- Definitive treatment
- Optimally done within 6 hour of disease onset
- If symptoms < 6 hour
- If symptoms > 6 hour
- Followed by fracture stabilization and vascular repair
- Follow-up debridement within 3 days and closure of the wound (View image)
- Recommended compartment pressures > 30 mmHg
- If in doubt, perform fasciotomy
- Contraindicated after 3 days due to risk on infections
- Amputation
- Life-saving in cases of delayed treatment or when fasciotomy is contraindicated
- Complications
- Peroneal nerve palsy
- Muscular damage
- Infection
- Sepsis
- Acute renal failure
- Hyperkalemia
- Dysrhythmias
- Gangrene
- ARDS
- Venous insufficiency after fasciotomy
- Contractures
- Hypesthesia
Disposition
- Admission Criteria
- Admit all patient
- Surgical candidates
- Consults
- Discharge/Follow-up instructions
- Follow-up debridement within 3 days of fasciotomy
- Skin grafts, if needed
References
- Matsen FA 3rd. Compartmental syndrome. An unified concept. Clin Orthop Relat Res. 1975;(113):8-14.
- Daniels M, Reichman J, Brezis M. Mannitol treatment for acute compartment syndrome. Nephron. 1998;79(4):492-493.
- McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. J Bone Joint Surg Am. 2013;95(8):673-677.
- Naidu KS, Chin T, Harris C, Talbot S. Bilateral peroneal compartment syndrome after horse riding. Am J Emerg Med. 2009;27(7):901.e3-5.
- Mubarak SJ, Hargens AR. Acute compartment syndromes. Surg Clin North Am. 1983;63(3):539-565.
- Matsen FA 3rd, Winquist RA, Krugmire RB Jr. Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am. 1980; 62(2):286-291.
- Clayton JM, Hayes AC, Barnes RW. Tissue pressure and perfusion in the compartment syndrome. J Surg Res. 1977;22(4):333-339.
- King TW, Lerman OZ, Carter JJ, Warren SM. Exertional compartment syndrome of the thigh: a rare diagnosis and literature review. J Emerg Med. 2010;39(2):e93-99.
- Rafiq I, Anderson DJ. Acute rhabdomyolysis following acute compartment syndrome of upper arm. J Coll Physicians Surg Pak. 2006;16(11):734-735.
- Shadgan B, Pereira G, Menon M, et al. Risk factors for acute compartment syndrome of the leg associated with tibial diaphyseal fractures in adults. J Orthop Traumatol. 2014;28.
- Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK448124/. [Accessed February 2024]
Contributor(s)
- Ballarin, Daniel, MD
- Ho, Nghia, MD
Updated/Reviewed: February 2024