Compartment Syndrome

Question 1

Explain compartment syndrome

Answer 1

Defined as a critical pressure increase within a confined compartmental space.

Any fascial compartment can be affected.

Most common sites are leg, thigh, forearm, foot, hand and buttock.

Question 2

Pathophysiology

Answer 2

High-energy trauma, crush injuries or fractures that cause vascular injury.

The fascial compartments are closed and cannot be distended meaning that any fluid that is deposited therein will cause increase in the intra-compartmental pressure.

The veins then become compressed leading to increase in hydrostatic pressure within the veins.

Fluid moves out of the veins into the compartment and increases the pressure further.

Then traversing nerves are compressed leading to symptoms.

As the intra-compartmental pressure reaches the diastolic pressure the arterial inflow will be compromised and cause ischaemia.

Question 3

Clinical features

Answer 3

Present within hours of injury or can take up to 48hs post.

Severe pain disproportionate to injury

Not readily imporved with initial measures like analgesia and elevation.

Pain is made worse by passively stretching muscles bellies.

Question 4

Examination findings

Answer 4

Paraesthesia

Affected compartment may feel tense

Not generally any swelling present

Acute arterial insufficiency can develop with the 6Ps.

Question 5

Ix

Answer 5

Clinical diagnosis

Should always have a high degree of clinical suspicion for compartment syndrome post-operatively.

Most reliable diagnostic test is intra-compartmental pressure monitor.

Creatine kinase levels may aid diagnosis as well.

Question 6

Key management

Answer 6

Early recognition
Immediate surgical treatment by urgent fasciotomies

Question 7

Initial management before definitive intervention

Answer 7

Keep limb at a neutral level (do not elevate or lower)

Improve O2 delivery with high flow.

Augment blood pressure with bolus or IV crystalloid fluids

Remove all dressings, splints, casts

No layers of any dressing must be left around their limb.

Treat symptomatically with opioid analgesia usually IV

Question 8

Post-op management after fasciotomy

Answer 8

Skin incisions are left open and a re-look is planned for 24-48 hours.

Review of dead tissue is done.

Once happy that all remaining tissues are healthy the wounds can be closed.

Monitor renal function closely due to rhabdomyolysis and reperfusion injury.