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Acute Compartment Syndrome

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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

Acute-Compartment-Syndrome-1
Acute-Compartment-Syndrome


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

Read about – ✅Acute Cartilage Injuries

Read related article- ✅Joint Dislocation/subluxation,Complications in joint

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Dr .Lalit Choudhary
Hii everyone, I'm Dr Lalit Choudhary PT. Born and brought up in delhi. Practicing as a professional PHYSIOTHERAPIST. As a therapist I love to interact with others and and get myself updated regarding all the social issues which are leading my countrymen to distress themselves. Yes, I agree that Iam a workaholic but my work gives me immense pleasure but there are sometimes when I feel stressed up so to relax myself I travel to new places, meet new people and try to adopt their culture. Most of the time I like to travel hills as it helps me to relax and enjoy our nature beauty. For being a good therapist and to deal with all the difficulties I always prefer to be good listener and have good patience that is what my strength is. I also work as a social worker and the Founder of thesocialphysiofitnessclub and PHYSIO FIT INDIA. In last I just want to say that " I believe that physical therapy is not just a therapy but actually a remedy which not only make you physically fit but also adds happiness, joy and more days to your life." So don't just sit and thought now it's time to stand and work on yourself.

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