History
■ Definition: Increased pressure in a confined tissue space that reduces capillary blood flow below a level necessary for viability of normal tissue
■ Etiology 1: Increased volume within a closed space (i.e., trauma, hemorrhage, or reperfusion injury)
■ Etiology 2: Decreased size of an enclosed space (i.e. cast, constrictive dressing, or MAST trousers)
Pathogenesis
■ Muscle injury: edema/hemorrhage – Increased pressure in enclosed space – ischemia – further soft tissue damage
■ Circulatory injury: Swelling with reperfusion – increased pressure in enclosed space – ischemia – further soft tissue damage
■ Muscle ischemia reversible up to 4 hours, irreversible after 8
■ Nerve ischemia results in reversible neuropraxia under 3 hours and irreversible after 8
Compartments
■ Anterior
■ Lateral
■ Deep posterior
■ Superficial posterior
Physical exam
■ Five P’s: Pain, Pallor, Paresthesias, Pulselessness, Paralysis
■ Pain out of proportion to injury
■ Pain with passive stretch of foot
■ Pallor skin tone
■ Loss of or decreased pulses (uncommon and/or a very late finding)
■ Paralysis or sensory changes after ischemia >1 hour
■ Tense, swollen compartments (most sensitive finding)
■ Glossy appearance of skin
Studies
■ Labs
➣ Elevated CPK values are common with ischemia but also elevated in trauma
■ Compartment pressure measurement
➣ Indicated in polytrauma, obtunded patient, or with inconclusive
Clinical diagnosis
➣ Direct measurement of involved compartments using needle catheter such as a Stryker STIC catheter, WICK catheter, or transducer from arterial line
➣ Pressure threshold requiring fasciotomy is controversial.
➣ Multiple sampling sites, with the highest value recorded and used to determine the need for fasciotomy
➣ Fasciotomy recommended with a measured pressure >35 mmHg or a pressure 20 mmHg below the measured diastolic blood pressure (number varies)
Differential diagnosis
■ Compartment syndrome is a surgical emergency. If clinically suspected, then the diagnosis is compartment syndrome until proven otherwise.
Treatment
■ Nonoperative
➣ Remove compressive dressings, casts, etc.
➣ Elevate leg to level of heart only.
➣ Compartment measurements if clinically suspicious
■ Operative
➣ Two-incision fasciotomy to decompress compartments
➣ Anterolateral incision – half the distance between fibula and tibial crest; used to decompress the anterior and lateral compartments
➣ Beware exiting superficial peroneal nerve through fascial defect distally
➣ Posterior medial incision – 2 cm posterior to medial tibia
➣ Delayed primary closure at 4–7 days with possible skin graft if needed
Disposition
N/A
Prognosis
■ Good if recognized and treated early
■ Poor if delayed diagnosis and/or intervention
Complications
■ Infection
■ Claw toes
■ Dysfunctional extremity
■ Amputation
Caveats and pearls
■ Early recognition is the key to successful treatment.
■ Remember the five P’s.
■ If you are thinking about checking the compartment pressures,
check them!
■ Acute compartment syndrome is a surgical emergency
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