Compartment Syndrome

Question 1

What is compartment syndrome?

Answer 1

• It is defined as an increased pressure within a fibro-osseous space resulting in decreased tissue perfusion to structures within that space
• Can be either acute or chronic
• Acute compartment syndrome is a diagnosis based on high index of suspicion, mechanism of injury and signs and symptoms

Question 2

What is the difference between acute/chornic compartment syndrome?

Answer 2

• Acute compartment syndrome is a medical emergency; usually precipitated by a severe injury; without treatment leads to permanent damage
• Chronic compartment syndrome, also names exertional compartment syndrome is not a medical emergency. Normally caused by athletic exertion

Question 3

How does compartment syndrome occur?

Answer 3

1. Compartment syndrome develops when swelling or bleeding occurs within a compartment.
2. Since the fascia does NOT stretch, increased pressure on capillaries, nerves and muscles can occur in the anatomical compartment
3. Without a steady supply of oxygen/nutrients, nerve and muscle cells can be damaged.
4. In acute compartment syndrome, unless pressure is relieved quickly (usually by a fasciotomy), permanent disability and tissue death may occur.
5. Compartment syndrome MOST OFTEN occurs in the anterior (front) compartment of the low leg.
6. It can also occur in other compartments in the leg, as well as the arms, hands, feet and buttocks.

Question 4

What are the 6 physical exam findings seen in patients with compartment syndrome?

Answer 4

The six (6) P’s:

1. Pain - on passive stretch of affected compartment
2. Paresthesia’s - following a dermatome pattern
3. Paralysis - of affected limb – late finding
4. Pulses - decreased or absent (late finding)
5. Pallor - rubor early in the course due to compensatory vasodilation and pallor of the affected limb late in the course
6. Poikilotherma - limb becomes ice cold or same temperature as environment\

The 3 MAIN findings that point a provider towards compartment syndrome are:

1. Pain out of proportion to expectation
2. Stretch pain- pain exacerbated by passive movement/stretch of the muscles
3. Tense swelling

Question 5

What are early signs associated with compartment syndrome?

Answer 5

1. Pain – Initial sign severe and out of proportion to the injury; especially when the muscle in within the compartment is stretched
2. Paresthesia’s- burning, tingling sensations in the skin; (early finding)
3. Pressure/Tightness/swelling or fullness of the muscle (early finding)

Question 6

What are late signs associated with compartment syndrome?

Answer 6

1. Numbness and paralysis are late signs; usually indicating permanent tissue injury
2. Pallor in affected extremitiy

Question 7

How are the compartment pressures calculated in compartment syndrome?

Answer 7

Calculate the delta pressure: the diastolic blood pressure minus the compartment pressure

• If the difference is < 30, then acute compartment syndrome present.
• Normal compartment pressures are 0 – 8 mmHg

Question 8

What lab tests are ordered for patients with compartment syndrome?

Answer 8

• CBC - Will have Elevated WBC
• BMP - Monitor for elevated K+ due to tissue necrosis
• EKG - Monitor for peaked T waves (due to increased extracellular K+)
• Urinalysis: + myoglobin
• Creatine phosphokinase (CPK) and lactate dehydrogenase: elevated

Question 9

How do you manage a patient with compartment syndrome?

Answer 9

Non-surgical management:

• There is NO non-surgical definitive treatment for ACS
• Position limb at level of heart; no elevation of limb
• Remove any constricting dressings or casting material – critical step!
• Serial neurovascular assessment of patient
• Compartment pressure measurements- serially
• Calculation of delta pressure

Surgical management:

• STAT surgical consult: Fasciotomy of affected compartment
• Delayed closure of fasciotomy wounds (5-7 days)
• Negative pressure wound vacuum dressings can be used along with oxygen therapy- hyperbaric. These have been shown to be beneficial in recent studies
• Skin grafting if indicated
• Amputation if indicated.

Restorative management:

• Functional splinting- especially ankle foot orthosis (AFO) for lower extremity compartment syndrome to prevent heel cord shortening
• PT: Active/passive ROM and strengthening exercises
• If amputation: early prosthetic fitting and ambulation