Compartment syndrome - NYSORA

Explore NYSORA knowledge base for free:

Compartment syndrome

Learning objectives

  • Pathophysiology of compartment syndrome
  • Management of compartment syndrome

Definition and mechanism

  • Compartment syndrome is an orthopedic emergency and occurs when the pressure within a compartment increases
  • Is essentially soft tissue ischemia, generally associated with trauma, fracture with subsequent casting, prolonged malpositioning during surgery, or reperfusion injury
  • Because various osseofascial compartments have a relatively fixed volume, excess fluid or external constriction increases pressure within the compartment and decreases tissue perfusion
  • The tissue hypoperfusion results in tissue hypoxia impeding cellular metabolism
  • If prolonged, permanent myoneural tissue damage occurs
  • As tissue pressure increases, extrinsic venous luminal pressure is exceeded, resulting in vein collapse
  • Normal compartment pressure should be within 12-18 mmHg, a pressure above 18 mmHg is considered abnormal
  • It is generally agreed that compartmental pressures greater than 30 mmHg require emergent intervention because ischemia is imminent
  • Hypoxic injury causes cells to release free radicals, which increases endothelial permeability, leading to a vicious cycle of continued fluid loss, further increasing tissue pressure and injury

Compartment syndrome NYSORA

Signs and symptoms

Acute compartment syndromeChronic compartment syndrome
CharacteristicsOccurs gradually, usually during and immediately after repetitive exercise
Usually passes within minutes of stopping the activity
Happens suddenly, usually after a fracture or severe injury
A medical emergency that required urgent treatment
Can lead to permanent muscle damage if not treated quickly
Occurs gradually, usually during and immediately after repetitive exercise
Usually passes within minutes of stopping the activity
Is not a medical emergency and does not cause permanent damage
Signs and symptomsIntense pain, especially when the muscle is stretched, which seems much worse than would normally be expected for the injury
Tenderness in the affected area
Tightness in the muscle
Paresthesia
Numbness or weakness
Cramping pain during exercise, most often in the legs
Swelling or a visibly bulging muscle
A tingling sensation
The affected area turning pale and cold
In severe cases, difficulty moving the affected body part

Etiology of acute compartment syndrome

Conditions that increase the compartment volumeConditions that lead to a reduction in the volume of tissue compartments
Direct soft tissue trauma with or without a long bone fracture
Closed tibial shaft fractures and closed forearm fractures
Soft tissue crush injuries
Open fractures, which should theoretically decompress the adjacent compartments
Hemorrhage: vascular injury, coagulopathy
Anticoagulation therapy
Revascularization of a limb after ischemia
High-energy trauma, such as from high-speed motor vehicle accident or crush injury
Increased capillary permeability after burns
Infusions or high-pressure injections
Extravasations of arthroscopic fluid
Reperfusion after prolonged periods of ischemia
Anabolic steroid use
Decreased serum osmolarity (eg, nephritic syndrome)
Strenuous exercise, especially in previously sedentary people
Tight circumferential dressings
Closure of fascial defects
Cast or splint, especially if placed before removal of the surgical tourniquet
Prolonged limb compression, as in Trendelenburg and lateral decubitus positions
Excessive traction to fractured limbs

Complications of acute compartment syndrome

Diagnosis

  • Based on clinical signs and symptoms
  • Pain out of proportion to the injury, especially with passive stretch of the muscles in the suspicious compartment or limb
  • A palpable tense extremity compared with the uninjured limb
  • Paresthesia – late clinical sign
  • Paresis – even later clinical sign
  • Measure compartment pressure
  • Maintain adequate pain control with the lowest possible dose in an attempt to avoid a delayed diagnosis of compartment syndrome

Management

compartment syndrome, perioperative hypotension, fasciotomy, diastolic pressure, debridement, necrotic muscle, rhabdomyolysis, hyperkalemia, myoglobinuria, acute kidney injury, hyperbaric oxygen therapy

Regional anesthesia and compartment syndrome

  • Be cautious with regional anesthesia, as it may obscure signs and symptoms of acute compartment syndrome
  • Avoid neuroaxial or periperhal regional techniques that result indense blocks of long duration
  • Single-shot or continuous peripheral nerve blocks using lower concentrations of local anesthetic agents without adjuncts are considered safe as they are not associated with delays in diagnosis

Suggested reading

  • Nathanson, M.H., Harrop‐Griffiths, W., Aldington, D.J., Forward, D., Mannion, S., Kinnear‐Mellor, R.G.M., Miller, K.L., Ratnayake, B., Wiles, M.D., Wolmarans, M.R., 2021. Regional analgesia for lower leg trauma and the risk of acute compartment syndrome. Anaesthesia 76, 1518–1525.
  • Farrow C, Bodenham A, Troxler M. 2011. Acute limb compartment syndromes. Continuing Education in Anaesthesia Critical Care & Pain. 11;1:24-28.
  • https://www.nysora.com/topics/sub-specialties/acute-compartment-syndrome-limb-implications-regional-anesthesia/

We would love to hear from you. If you should detect any errors, email us customerservice@nysora.com