Compartment Syndrome Flashcards
Define compartment syndrome
Pathological condition characterised by elevated interstitial pressure in a closed osteofascial compartment that results in microvascular compromise (restriction of capillary blood flow)
Aetiology of compartment syndrome
Commonly involves the anterior and deep posterior compartments of the leg and the volar compartment of the forearm (relatively non-compliant osseous or fascial structures)
Fractures (69%) - espeically tibial
Soft-tissue injury
Extremity compression → vascular compromise
Reperfusion of chronically ischaemic extremities
Burn injuries to extremities
Iatrogenic - IV fluid extravasation or aggressive fluid resuscitation
Prolonged immobilisation and post-arthroplasty anaglesia
Chronic exertional compartment syndrome: long-distance runners
Risk factors for compartment syndrome
Trauma
Bleeding disorders
Compression support
Thermal injury
Intense muscular activity
Extravasation of IV infusion
Venous obstruction
Symptoms and signs of compartment syndrome
Pain
- Classically out of proportion to the injury/clinical situation
- Exacerbated by passive stretching of the involved muscle
- Does not improve with adequate analgesia
Pressure/muscle tightness
Paraesthesia
Paralysis
Affected compartment feels tense
Paralysis
Differentials for compartment syndrome
DVT
Stress fracture
Acute ischaemia
Chronic venous insufficiency
Muscle tear
Haematoma
Extremity fracture
Investigations for compartment syndrome
Clinical diagnosis - treat immediately
Urine myoglobin: elevated from muscle cell lysis and muscle necrosis
CK: elevated
Troponin: elevated
U&Es: ?Rhabdo
Intra-compartmental pressure monitor: >20 = abnormal, >40 diagnostic
- For clinical uncertainty only
Management for compartment syndrome
As soon as suspected → urgent fasciotomy
- skin incision left open
- Re-look in 24-48 hours
Supportive:
Keep the limb at a neutral level with the patient (do not elevate or lower)
Improve oxygen delivery with high flow oxygen
Augment blood pressure with bolus of intravenous crystalloid fluids
- This transiently improves perfusion of the affected limb
Remove all dressings / splints / casts, down to the skin (no layers of any dressing must be left circumferentially)
Treat symptomatically with opioid analgesia (usually intravenous), can consider NSAIDs beforehand
Monitor renal function (?rhabdo, reperfusion)
Muscle necrosis → amputate
Complications of treatment for compartment syndrome
Amputation
- Phantom pain
Fasciotomy
- Wound infection
- Sensory deficits
- Tethered tendons
- Recurrent ulceration
Complications of compartment syndrome
Limb loss
Rhabdomyolysis → Acute renal failure
Sensory deficits
Motor deficits
Volkmann’s ischaemic contracture (forearm)
Prognosis for compartment syndrome
Fasciotomy performed within a 6-hour window from the initiation of compartment syndrome leads to lower compartment syndrome-related amputation and death rates
Tissue ischaemia of only 1 hour is associated with reversible neuropraxia, whereas ischaemia of 4 hours can induce irreversible axonal nerve damage
