Compartment syndrome

Last updated: Apr 30, 2020

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CLINICAL SCIENCES
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Summary
Compartment syndrome is a condition in which increased pressure within a muscle compartment (containing nerves and vasculature, enclosed by
unyielding fascia) leads to impaired tissue perfusion. It most commonly affects the lower legs, but can also occur in other parts of the extremities or
the abdomen. Compartment syndrome may be acute (e.g., after trauma) or chronic (e.g., collectively excessive training in athletes). Acute
compartment syndrome is a surgical emergency that initially presents with rapidly progressive pain, paresthesia, and pallor. Pronounced neurological
symptoms with motor deficits, absent pulses, and poikilothermia occur later on and indicate irreversible damage. This diagnosis should be suspected
in the presence of typical clinical findings and then confirmed via measurement of compartment pressures. Acute compartment syndrome requires
early fasciotomy (an incision through the fascia) within six hours of onset to prevent severe ischemic necrosis. Chronic compartment syndrome is
also often associated with pain; it can be exacerbated by exercise and relieved by rest, and is usually managed with conservative treatment. The
prognosis of compartment syndrome is generally good with early and appropriate management.
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Etiology
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The etiology of compartment syndrome

External compressing forces Internal expanding forces

Trauma-  Burn eschars  Hematoma and edema from long bone fractures
related  Constrictive bandage/cast  Blood vessel injury with hemorrhage
 Repetitive muscle use (esp. excessive running, seizures)
 Crush injury
 Penetrating injuries (e.g., gunshot and stab wounds)
 Burn edema
 Reperfusion syndrome with ischemia-reperfusion edema
 Edema from venomous animal bites (especially snake bites)
 The etiology of compartment syndrome

External compressing forces Internal expanding forces

Non-traumatic  Incorrect positioning limbs (e.g., immobile patient)  Increased capillary permeability, e.g., shock
 Coagulopathies

Peripheral circulation is reduced in polytrauma patients with shock. Therefore, increased compartment pressure in polytrauma patients is associated
with an early, high risk of muscle ischemia!
References: [1]

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Classification
 Acute compartment syndrome: predominantly trauma-induced; a surgical emergency!

 Chronic compartment syndrome: also known as exertional compartment syndrome; usually not a medical emergency
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Pathophysiology
External or internal forces as initiating event → increased compartment pressure → decreased tissue perfusion → lower oxygen supply to
muscles → irreversible tissue damage to muscles and nerves after 4–6 hours of ischemia
References: [1]

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Clinical features
Compartment syndrome may occur in any enclosed muscle compartment inside the body. The most common sites are the lower legs and arms. Less
common sites include the feet, hands, thighs, and gluteal region.
Acute compartment syndrome (ACS)
Typically presents with a rapid progression of symptoms.
Early presentation

 Pain
 o Often out of proportion to the extent of injury

o Worse with passive stretching or extension of muscles

o Very tight, wood-like muscles that are extremely tender to touch

 Paresthesia (e.g., pins and needles)

 Soft tissue swelling

 Initially, peripheral circulation and distal pulses are maintained.

Late presentation

 Muscle weakness to paralysis

 Absent (or weak) distal pulses

 Cold peripheries

 Pallor

or cyanosis

 Worsened pain and swelling

6 P's of acute limb ischemia: Pain, Pallor, Paresthesias, Poikilothermia, Pulselessness, and Paralysis!
Arterial pulse is usually still palpable; pulselessness is a sign of very severe compartment syndrome!
Chronic compartment syndrome
 Usually affects the lower leg

 Muscle pain, weakness, and swelling exacerbated by exercise and relieved with rest [2]

References: [3][4]

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Subtypes and variants

Anterior compartment syndrome of the lower leg
 Most common type of acute compartment syndrome

 Clinical presentation
o Motor: toe dorsiflexion weakness

o Sensory: loss of sensation/paresthesia in the nerve territory

 Treatment: surgery (dermato-fasciotomy)

Abdominal compartment syndrome
 Etiology:
o Primary

 Penetrating abdominal trauma

 Pelvic trauma

 Rupture of abdominal aortic aneurysm

o Secondary

 Massive volume resuscitation (e.g., postoperative patients, treatment of hypovolemic shock, severe burns)

 Severe ascites

 Abdominal surgery

 Sepsis

 Pathophysiology: ↑ intra-abdominal pressure

→ organ dysfunction

 Clinical features: may develop within hours or over days

o Critically ill patient
 o Cardiovascular: signs of increased central venous pressure (e.g., distended jugular veins), hypotension, tachycardia

o Renal: oliguria, progressive renal failure

o Gastrointestinal: tight, distended abdomen, nausea, vomiting

o Pulmonary: tachypnea, wheezing

 Diagnostics:
o Best initial test: indirect measurement of intra-abdominal pressure

o CT imaging: increased abdominal diameter, compression of the inferior vena cava, intestinal wall thickening, bilateral
inguinal herniation
o Abdominal x-ray: not useful for detecting abdominal compartment syndrome

 Treatment
o Abdominal decompression

 Laparotomy for decompression

 Temporary abdominal closure (e.g., patch technique, vacuum-assisted closure)

 Definitive closure
o Supportive management

 Percutaneous drainage of intra-abdominal fluid

 Hemodynamic stabilization (e.g., fluid resuscitation, transfusions)

 Ventilation

References: [3][5]

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Diagnostics
Compartment pressure measurement is necessary to confirm the diagnosis. Further laboratory tests are unnecessary but should be performed
in trauma-related compartment syndrome to assess for rhabdomyolysis. Imaging may be useful to identify an underlying etiology.
  Compartment pressures (initial and confirmatory test): measurement of tissue pressure with a manometer and calculation
of delta pressures (delta pressure = diastolic - (compartment) tissue pressure)
o Delta pressure in manifest compartment syndrome: ≤ 30 mm Hg

 Laboratory tests specific for rhabdomyolysis

 Imaging
o X-rays

 Pulse oximetry: not diagnostic but can help identify limb hypoperfusion

References: [1][3]

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Differential diagnoses
 Deep vein thrombosis

 Acute limb ischemia

 Rhabdomyolysis (often also a complication of compartment syndrome)

 Cellulitis

 Peripheral artery disease

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History Clinical presentation Tests Treatment

Acute  Traumatic  Deep pain out of  Delta pressure ≤ 30 mm Hg  Surgical and

compartment or non- proportion to the injury supportive treatment
syndrome traumatic  6 P's

Deep vein  Immobility,  Often asymptomatic  Wells score  Anticoagulation

thrombosis surgery  Nonspecific pain and calf  Doppler ultrasound  Thrombolysis
 Pregnancy swelling
 History Clinical presentation Tests Treatment

 Clotting
disorder

Acute limb  Atrial  Acute onset (embolism) or  Doppler ultrasound (best  Anticoagulation
ischemia fibrillation subacute onset initial test)  Revascularization
(arterial thrombosis)
 Peripheral  Digital subtraction (interventional or
artery disease  6 P's angiography (confirmatory surgical)
test)

Rhabdomyolysis  Crush injury  Myalgia  Blood: ↑  IV fluid

CK, ↑ LDH, ↑ myoglobin administration
 Seizure  Generalized weakness
 Urine: myoglobinuria
 Adverse drug  Darkened urine (red to
reactions brown)

References: [1]

The differential diagnoses listed here are not exhaustive.

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Treatment
 Surgical treatment: required for all cases of acute compartment syndrome!
o Also indicated if conservative treatment fails in chronic compartment syndrome.

o Fasciotomy (tissue and fascia incisions): relieves the pressure, thus restoring perfusion

 Should be conducted within 6 hours after the onset of the condition to prevent necrosis

 Followed by open wound treatment

o Fibulectomy: if fasciotomy fails; to decompress all compartments of the lower leg

o Escharotomy: in the case of circumferential compression by a burn eschar

o Last resort: amputation

  Supportive treatment
o Indicated as perioperative care

o Eliminate any underlying cause, e.g., remove restrictive cast/dressing

o Cooling and positioning of the limb at heart level to relieve pressure

o Close monitoring

o Correct any fluid imbalances

o Supplemental oxygen

o Analgesia

Elevated positioning may worsen ischemia by reducing blood flow!

Acute compartment syndrome is a surgical emergency and requires an early fasciotomy!

References: [3][6][2]

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Complications
 Muscle and soft tissue necrosis with a higher risk of infection

 Nerve lesions (esp. the tibial nerve and peroneal nerve) with sensory and motor deficits or paralysis

 Fracture malalignment

 Rhabdomyolysis with potential Crush syndrome

 Muscle contractures

 Rebound compartment syndrome

 o Occurs 6–12 hours after surgical reperfusion

o Etiology: increased capillary permeability and edema, often due to insufficient fasciotomy incisions

 Volkmann contracture
o Permanent flexion contracture due to shortening of forearm muscles (“claw-like deformity” of the hand, fingers, and wrist)

o Direct complication of insufficient treatment or undiagnosed compartment syndrome

References: [3][6][7]

We list the most important complications. The selection is not exhaustive.

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Prognosis
The prognosis depends on the amount of time that has elapsed prior to performing the fasciotomy:

 ≤ 6 h: almost complete recovery

 6–12 h: first necroses; normal limb function returns in 68% of cases

 ≥ 12 h: necroses; normal limb function returns in 8% of cases