Compartment syndrome

Compartment syndrome
Classification and external resources

Fasciotomy, covered with a skin graft. 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 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 compartments 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 increased intra-compartmental pressure due to the

accumulation of necrotic debris and haemorrhage, especially haemorrhage secondary to 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). Rhabdomyolysis and subsequent renal failure are also possible complications