Compartment Syndrome

Compartment SyndromeCompartment syndrome, if not identified and acted upon early, will result in irreversibledamage to neuromuscular soft tissue. Therefore, the healthcare professional must be awareof the risks, signs and symptoms, unusual circumstances, and appropriate interventions withthis syndrome. Compartment syndrome is a life-threatening condition in which increasedtissue pressure in a confined anatomical space causes decreased blood flow leading toischemia and dysfunction of contained myoneural elements. It is marked by pain, muscleweakness, sensory loss, and palpable tenseness in the involved compartment. Ischemia canlead to necrosis resulting in permanent impairment of function. Increased pressure withinthe compartment results from bleeding and swelling into the closed space which in turncauses pressure on the vital structures. There is elevation of interstitial pressure in a closedfascial compartment that results in microvascular compromise. As the duration andmagnitude of interstitial pressure increases, myoneural function is impaired and necrosis of soft tissues eventually develops. Compartment syndrome can occur where there issignificant edema in a compartment within the hand, forearm, upper arm, buttock, legs,feet, and occasionally the abdomen. Usually compartment syndrome occurs due tofractures of the tibia or forearm, in vascular injuries, or burns. Almost any injury or surgerycan cause the condition.PhysiologyArteries and their subdivisions bring freshly oxygenated blood to the tissues, and theassociated venous system returns deoxygenated blood to the venous circulation. Thehuman body has a number of areas that function as closed compartments to this deliverysystem. There are three main compartments in the forearm and four main compartments inthe lower leg. The long bones of the limbs, for example, are joined and surrounded bysheets of tough and relatively inelastic tissue called fascia which create comparativelyinflexible boundaries. The placement of the fascia is such as to divide the leg, for instances,into a number of sections or compartment. These compartments contain muscles, arteries,veins, and nerves. These compartments generally have a fairly constant volume that permitsonly slight variation. If swelling occurs in these compartments the subsequent rise incompartment pressure can cause serious damage.The arterial blood system continues to bring blood into the compartment, but low pressureveins and their subdivision have a low intra-luminal pressure that is restricted. When thisoccurs it is further compounded by the release of fluid from the blood vessels resulting in afurther rise in compartment pressure that perpetuates the cycle. Edema within the closedcompartment will increase the pressure within that compartment eventually compromisingthe vascular supply. Such compromise will lead to further ischemia and edema formation. Avicious cycle will be established as cells become deprived of oxygen.Subsequent necrosis of muscle and loss of capillary wall integrity will lead to transudation,exudation, and the development of massive edema within the compartment.Rhabdomyolysis then occurs. Rhabdomyolysis is the dissolution or breakdown, of striatedmuscle that results in the production of myoglobin. Myoglobin is known to cause acuterenal failure. If untreated, rhabdomyolysis may lead to myoglobinuria, permanent

Compartment Syndrome

neurovascular damage, renal failure, sepsis, and even death. This occurs as the myoglobin isreleased into the circulation where it can occlude the distal convoluted tubule andprecipitate renal failure.Significant fluid loss into damaged tissues leads to hypovolemia and metabolic acidosis. Thisnot only acts as a potent pre-renal cause for renal impairment but also enhances thenephritic effect of myoglobin. Severe metabolic complications may present afterreperfusion when the damaged membranes continue to leak, aggravating edema formationand increasing the pressure in the closed osteofascial compartment. Rhabdomyolysis is welldocumented as a secondary cause in a range of conditions related to skeletal muscle injury.The syndrome may develop as quickly as within the first 30 minutes to 1-2 hours posttrauma. Or it may develop postoperatively, post fracture reduction, or in as late as 5-6 days.If it is allowed to last for more than 6 hours, neuromuscular damage becomes irreversible.Splinting, traction, early closed reduction with casting, or early surgery for fractures reducethe risk of Compartment Syndrome.There are three categories of etiology:

Decreased compartment size can be caused by restrictive dressings, splints or casts,excessive traction, or premature closure of fascia.

Increased compartment content can be caused by a fracture that causes bleeding or froma vascular injury, burns, infiltrated IV infusion, swollen or inflamed bowel, or snakebites.The first response is to elevate the extremity. However, when the extremity is elevatedtoo high above heart level, this compromises arterial perfusion, which further compoundsthe ischemic problem.

Externally applied C can be caused from restrictive dressings, prolonged compressionfrom lying on a limb or crushing injuries of soft tissue.

Compartment Syndrome

Compartment Syndrome Pathophysiology

Insult/InjuryVascular C(Microvascular and Venous Congestion)HypoxiaCell Death and Protein ReleaseEdemaIncreased Intra-compartmental PressureFurther Cell DamageC NecrosisDeath AmputationPermanentDisabilitySigns and Symptoms

Compartment syndrome usually presents after reperfusion of a limb. Pain and swelling may notoccur immediately. The first signs usually occur after the patient has regained consciousness,undergone their post-anesthetic care, and returned to the unit. Often several hours are reported asuneventful before the first signs and symptoms are reported. The first suspicions are usually arousedwhen a patient complains of severe pain in the lower legs when they have recovered consciousnessor a few hours after surgery. Some patients may even describe pain despite postoperative epidural

anesthesia. The patient’s leg may appear tense and swollen. The level of pathological pain is found

to be far greater than the ordinary postoperative pain to be expected from the surgical intervention.The diagnosis of compartment syndrome requires a high index of clinical suspicion. Timing of identification and intervention with compartment syndrome is crucial to a positive patient outcome.It is possible that an initial diagnosis of deep vein thrombosis (DVT) may interfere with the correctdiagnosis. The measurement of compartment pressures will confirm the suspicions of compartment

syndrome while venous Doppler studies will confirm a DVT. Remember the “6 P’s” of compartment

syndrome:

ParesthesiaSubtle first symptom