Compartment syndrome

Compartment syndrome is the compression of nerves, blood vessels, and muscle inside
a closed space (compartment) within the body. This leads to tissue death from lack of
oxygenation, the blood vessels being compressed by the raised pressure within the compartment.
Compartment syndrome most often involves the forearm and lower leg. It can be divided into
acute, sub acute and chronic compartment syndrome.

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. Paresthesia, however, is a late symptom.

 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.

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. Another
possible cause can be the use of creatine monohydrate; a history of creatine use has been linked
to this condition. 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 pneumatic pressure Flowtron boots
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). This is usually not an emergency, but the loss
of circulation can cause temporary or permanent damage to nearby nerves and muscles.

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.

The normal mean interstitial tissue pressure is near zero in non-contracting muscle. If this
pressure becomes elevated to 30 mmHg or more, small vessels in the tissue become compressed,
which leads to reduced nutrient blood flow, ischemia and pain. Of particular importance is the
difference between compartment pressure and diastolic blood pressure; where diastolic blood
pressure exceeds compartment pressure by less than 30 mmHg it is considered an emergency.

Untreated compartment syndrome-mediated ischemia of the muscles and nerves leads to

eventual irreversible damage and death of the tissues within the compartment.

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 as an indication for fasciotomy while
others suggest a <30 mmHg difference between intracompartmental pressure and diastolic blood
pressure. 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.
Treatment
Acute compartment syndrome is a medical emergency requiring immediate surgical
treatment, known as a fasciotomy, to allow the pressure to return to normal.

Subacute compartment syndrome, while not quite as much of an emergency, usually

requires urgent surgical treatment similar to acute compartment syndrome.

Chronic compartment syndrome in the lower leg can be treated conservatively or

surgically. Conservative treatment includes rest, anti-inflammatories, elevation of the limb and
manual decompression. In cases where symptoms persist, the condition should 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 shown to be a useful adjunctive therapy for crush
injury, compartment syndrome, and other acute traumatic ischemias by improving wound
healing and reducing repetitive surgery.

Fasciotomy or fasciectomy is a surgical procedure where the fascia is cut to relieve

tension or pressure (and treat the resulting loss of circulation to an area of tissue or muscle).
Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. It is
also sometimes used to treat chronic compartment stress syndrome. The procedure has a very
high rate of success, with the most common problem being accidental damage to a nearby nerve.

There is a slight male predominance among people undergoing a fasciotomy.

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.

If left untreated, acute compartment syndrome can lead to more severe conditions
including rhabdomyolysis and kidney failure.
BATAAN PENINSULA STATE UNIVERSITY
College of Nursing and Midwifery
Balanga Campus

WRITTEN REPORT

Submitted by:
Armie John D. Baluyot
Group V- MTW