Compartment syndrome
Encyclopedia
Compartment syndrome is a limb threatening and life threatening condition, defined as the compression of nerves, blood vessels, and muscle inside a closed space (compartment
) within the body . This leads to tissue death from lack of oxygenation due to the blood vessels being compressed by the raised pressure within the compartment. Compartment syndrome most often involves the forearm and lower leg, and can be divided into acute, subacute, and chronic compartment syndrome.
An alternative definition of compartment syndrome, according to Rankin, is characterized by pressure within a closed space thus compromising the circulation and function of tissues in that space (Rankin, 1981).
that defines the compartment does not stretch, a small amount of bleeding into the compartment, or swelling of the muscles within the compartment, can cause the pressure to rise greatly. Common causes of compartment syndrome include tibia
l or forearm fractures, ischemic reperfusion following injury, hemorrhage, vascular puncture, intravenous drug injection, casts, prolonged limb compression, crush injuries and burns. Another possible cause can be the use of creatine monohydrate; a history of creatine use has been linked to this condition.
Compartment syndrome can also occur following surgery in the Lloyd Davis
lithotomy position
, where the patient's legs are elevated for prolonged periods. As of February 2001, any surgery that is expected to take longer than six hours to complete must include Compartment Syndrome on its list of post-operative complications. The Lloyd Davis lithotomy position can cause extra pressure on the calves and on the intermittent pneumatic compression
device worn by the patient.
When compartment syndrome is caused by repetitive use of the muscles, as in a cyclist, it is known as chronic compartment syndrome (CCS). This is usually not an emergency, but the loss of circulation can cause temporary or permanent damage to nearby nerves and muscles.
One cause of compartment syndrome is through exercise called Chronic Exertional Compartment Syndrome. According to Touliopolous, CECC of the leg is a condition caused by exercise which results in increase tissue pressure within a limited fibro - osseous compartment - muscle size may increase by up to 20% during exercise (Touliopolous, 1999) When this happens pressure builds up in the tissues and muscles causing tissue ischemia (Touliopolous, 1999). The cause of compartment syndrome is due to excess pressure on the muscle compartments. This pressure can occur for many different reasons, many are due to injuries. Injuries cause the swelling of tissue. The swelling of the tissue forces pressure upon the muscle compartments, which has a limited volume. Due to this pressure, the venules and lymphatic vessels that drain the muscle compartments are compressed, and are prevented from draining. As arterial inflow continues while outflow is decreased, the pressure builds up in the muscle compartments. This pressure will eventually decrease the amount of blood flow over the capillary bed, causing the tissue to become ischaemic. The tissues will release factors and will lead to the formation of edema.
of the soft tissue within the compartment further raises the intra-compartment pressure, which compromises venous and lymphatic drainage of the injured area. Pressure, if further increased in a reinforcing vicious circle, can compromise arteriole perfusion, leading to further tissue ischemia
. Untreated compartment syndrome-mediated ischemia of the muscles and nerves leads to eventual irreversible damage and death of the tissues within the compartment.
There are three main mechanisms that are hypothesized to cause compartment syndrome. One idea is the increase in arterial pressure (due to increased blood flow due to trauma or excessive exercise) causes the arteries to spasm and this causes the pressures in the muscle to increase even further. Second, obstruction of the microcirculatory system is hypothesized. Finally, there is the idea of arterial or venous collapse due to transmural pressure.
out of proportion to what is expected, paresthesia
, pallor
, paralysis
, pulselessness; sometimes a 6th P, for polar/poikilothermia (failure to thermoregulate) is added. Of these, only the first two are reliable in the diagnosis of compartment syndrome. Paresthesia, however, is a late symptom.
Some symptoms of compartment syndrome are paresthesia, palpable pulse, paresis and pallor. According to Shears paresthesia in the distribution of the nerves transversing the affected compartment has also been described as relatively early sign of compartment syndrome, and later is followed by anesthesia (Shears, 2006). The other three symptoms of compartment syndrome are palpable pulse, paresis and pallor. These symptoms are irreversible and consistent during compartment syndrome and its part of the diagnosis (Shears, 2006).
will be required to relieve the pressure. Various recommendations of the intracompartmental pressure are used with some sources quoting >30 mmHg as an indication for fasciotomy while others suggest a <30 mmHg difference between intracompartmental pressure and diastolic blood pressure. This latter measure may be more sensible in the light of recent advances in permissive hypotension
, which allow patients to be kept hypotensive in resuscitation. It is now relatively easy to measure compartment and subcutaneous pressures using the pressure transducer modules (with a simple intravenous catheter and needle) that are attached to most modern anaesthetic machines.
Most commonly compartment syndrome is diagnosed through a diagnosis of its underlying cause and not the condition itself. According to Blackman one of the tools to diagnose compartment syndrome is x-ray to show a tibia/fibula fracture, which when combined with numbness of the extremities is enough to confirm the presence of compartment syndrome.
, to allow the pressure to return to normal.
An acute compartment syndrome has some distinct features such as swelling of the compartment due to inflammation and arterial occlusion. Decompression of the nerve traversing the compartment might alleviate the symptoms (Rorabeck, 1984). It usually occurs in the upper or lower limb after an injury. During compartment syndrome there is decreased pressure due to the accumulation of necrotic debris and haemorrhage, especially haemorrhage to secondary fractures (Rorabeck, 1984). Acute compartment syndrome (ACS) of the lower extremity is a clinical condition that is seen fairly regularly in modern practice (Shagdan, 2010). Although pathophysiology of the disorder is well known to physicians who care for patients with musculoskeletal injuries, the diagnosis is often difficult to make (Shagdan, 2010). If left untreated, acute compartment syndrome can lead to more severe conditions including rhabdomyolysis
and kidney failure potentially leading to death.
Hyperbaric oxygen therapy has been suggested by case reports — though as of 2011 not proven in controlled randomized trials — to be an effective adjunctive therapy for crush injury, compartment syndrome, and other acute traumatic ischemias, by improving wound healing and reducing the need for repetitive surgery. The main treatment for compartment syndrome is surgery. There needs to be an incision in the skin so that the skin may be retracted back. Incisions are made in the affected muscle compartments so that they will decompress. This decompression will relieve the pressure on the venules and lymphatic vessels, and will increase bloodflow throughout the muscle.
Technology solutions for compartment syndrome involving continuous monitoring have also been proposed and tested.
of tissue in that compartment, since capillary perfusion will fall leading to increasing hypoxia
of those tissues. This can cause Volkmann's contracture
in affected limbs. As intercompartmental pressure rises during compartment syndrome, perfusion within the compartment is reduced leading to ischemia, which if left untreated results in necrosis of nerves and muscles of the compartment (Shears, 2006).
Compartment (anatomy)
In anatomy, a compartment is a space, mostly bounded by fascia , and sometimes also bone profoundly...
) within the body . This leads to tissue death from lack of oxygenation due to the blood vessels being compressed by the raised pressure within the compartment. Compartment syndrome most often involves the forearm and lower leg, and can be divided into acute, subacute, and chronic compartment syndrome.
An alternative definition of compartment syndrome, according to Rankin, is characterized by pressure within a closed space thus compromising the circulation and function of tissues in that space (Rankin, 1981).
Causes
Because the connective tissueConnective tissue
"Connective tissue" is a fibrous tissue. It is one of the four traditional classes of tissues . Connective Tissue is found throughout the body.In fact the whole framework of the skeleton and the different specialized connective tissues from the crown of the head to the toes determine the form of...
that defines the compartment does not stretch, a small amount of bleeding into the compartment, or swelling of the muscles within the compartment, can cause the pressure to rise greatly. Common causes of compartment syndrome include tibia
Tibia
The tibia , shinbone, or shankbone is the larger and stronger of the two bones in the leg below the knee in vertebrates , and connects the knee with the ankle bones....
l or forearm fractures, ischemic reperfusion following injury, hemorrhage, vascular puncture, intravenous drug injection, casts, prolonged limb compression, crush injuries and burns. Another possible cause can be the use of creatine monohydrate; a history of creatine use has been linked to this condition.
Compartment syndrome can also occur following surgery in the Lloyd Davis
Lloyd-Davies position
Lloyd-Davies position is a medical term referring to a common position for surgical procedures involving the pelvis and lower abdomen. The majority of colorectal and pelvic surgery is conducted with the patient in the Lloyd-Davis position....
lithotomy position
Lithotomy position
The lithotomy position is a medical term referring to a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen, as well as a common position for childbirth in Western nations...
, where the patient's legs are elevated for prolonged periods. As of February 2001, any surgery that is expected to take longer than six hours to complete must include Compartment Syndrome on its list of post-operative complications. The Lloyd Davis lithotomy position can cause extra pressure on the calves and on the intermittent pneumatic compression
Intermittent pneumatic compression
A therapeutic technique used in medical devices that include an air pump and inflatable auxiliary sleeves, gloves or boots in a system designed to improve venous circulation in the limbs of patients who suffer edema or the risk of deep vein thrombosis ....
device worn by the patient.
When compartment syndrome is caused by repetitive use of the muscles, as in a cyclist, it is known as chronic compartment syndrome (CCS). This is usually not an emergency, but the loss of circulation can cause temporary or permanent damage to nearby nerves and muscles.
One cause of compartment syndrome is through exercise called Chronic Exertional Compartment Syndrome. According to Touliopolous, CECC of the leg is a condition caused by exercise which results in increase tissue pressure within a limited fibro - osseous compartment - muscle size may increase by up to 20% during exercise (Touliopolous, 1999) When this happens pressure builds up in the tissues and muscles causing tissue ischemia (Touliopolous, 1999). The cause of compartment syndrome is due to excess pressure on the muscle compartments. This pressure can occur for many different reasons, many are due to injuries. Injuries cause the swelling of tissue. The swelling of the tissue forces pressure upon the muscle compartments, which has a limited volume. Due to this pressure, the venules and lymphatic vessels that drain the muscle compartments are compressed, and are prevented from draining. As arterial inflow continues while outflow is decreased, the pressure builds up in the muscle compartments. This pressure will eventually decrease the amount of blood flow over the capillary bed, causing the tissue to become ischaemic. The tissues will release factors and will lead to the formation of edema.
Pathophysiology
Any condition that results in an increase in compartment contents or reduction in a compartment’s volume can lead to the development of an acute compartment syndrome. When pressure is elevated, capillary blood flow is compromised. EdemaEdema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
of the soft tissue within the compartment further raises the intra-compartment pressure, which compromises venous and lymphatic drainage of the injured area. Pressure, if further increased in a reinforcing vicious circle, can compromise arteriole perfusion, leading to further tissue ischemia
Ischemia
In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
. Untreated compartment syndrome-mediated ischemia of the muscles and nerves leads to eventual irreversible damage and death of the tissues within the compartment.
There are three main mechanisms that are hypothesized to cause compartment syndrome. One idea is the increase in arterial pressure (due to increased blood flow due to trauma or excessive exercise) causes the arteries to spasm and this causes the pressures in the muscle to increase even further. Second, obstruction of the microcirculatory system is hypothesized. Finally, there is the idea of arterial or venous collapse due to transmural pressure.
Symptoms and signs
There are classically 5 "Ps" associated with compartment syndrome — painPain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
out of proportion to what is expected, paresthesia
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...
, pallor
Pallor
Pallor is a reduced amount of oxyhaemoglobin in skin or mucous membrane, a pale color which can be caused by illness, emotional shock or stress, stimulant use, lack of exposure to sunlight, anaemia or genetics....
, paralysis
Paralysis
Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...
, pulselessness; sometimes a 6th P, for polar/poikilothermia (failure to thermoregulate) is added. Of these, only the first two are reliable in the diagnosis of compartment syndrome. Paresthesia, however, is a late symptom.
Some symptoms of compartment syndrome are paresthesia, palpable pulse, paresis and pallor. According to Shears paresthesia in the distribution of the nerves transversing the affected compartment has also been described as relatively early sign of compartment syndrome, and later is followed by anesthesia (Shears, 2006). The other three symptoms of compartment syndrome are palpable pulse, paresis and pallor. These symptoms are irreversible and consistent during compartment syndrome and its part of the diagnosis (Shears, 2006).
- Pain is often reported early and almost universally. The description is usually of severe, deep, constant, and poorly localized pain, sometimes described as out of proportion with the injury. The pain is aggravated by stretching the muscle group within the compartment and is not relieved by analgesia up to and including morphineMorphineMorphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
. - Paresthesia (altered sensation e.g. "pins & needles") in the cutaneous nerves of the affected compartment is another typical sign.
- Paralysis of the limb is usually a late finding. The compartment may also feel very tense and firm (pressure). Some find that their feet and even legs fall asleep. This is because compartment syndrome prevents adequate blood flow to the rest of the leg.
- Note that a lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often well below arterial pressures and pulse is only affected if the relevant artery is contained within the affected compartment.
- Tense and swollen shiny skin, sometimes with obvious bruising of the skin.
- Congestion of the digits with prolonged capillary refill time.
Diagnosis
Compartment syndrome is a clinical diagnosis. However, it can be tested for by gauging the pressure within the muscle compartments. If the pressure is sufficiently high, a fasciotomyFasciotomy
Fasciotomy or fasciectomy is a surgical procedure where the fascia is cut to relieve tension or pressure . Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. It is also sometimes used to treat chronic compartment stress syndrome...
will be required to relieve the pressure. Various recommendations of the intracompartmental pressure are used with some sources quoting >30 mmHg as an indication for fasciotomy while others suggest a <30 mmHg difference between intracompartmental pressure and diastolic blood pressure. This latter measure may be more sensible in the light of recent advances in permissive hypotension
Permissive hypotension
Permissive hypotension or hypotensive resuscitation is a term used to describe the use of restrictive fluid therapy, specifically in the trauma patient, that increases systemic pressure without reaching normotension...
, which allow patients to be kept hypotensive in resuscitation. It is now relatively easy to measure compartment and subcutaneous pressures using the pressure transducer modules (with a simple intravenous catheter and needle) that are attached to most modern anaesthetic machines.
Most commonly compartment syndrome is diagnosed through a diagnosis of its underlying cause and not the condition itself. According to Blackman one of the tools to diagnose compartment syndrome is x-ray to show a tibia/fibula fracture, which when combined with numbness of the extremities is enough to confirm the presence of compartment syndrome.
Acute compartment syndrome
Acute compartment syndrome is a medical emergency requiring immediate surgical treatment, known as a fasciotomyFasciotomy
Fasciotomy or fasciectomy is a surgical procedure where the fascia is cut to relieve tension or pressure . Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. It is also sometimes used to treat chronic compartment stress syndrome...
, to allow the pressure to return to normal.
An acute compartment syndrome has some distinct features such as swelling of the compartment due to inflammation and arterial occlusion. Decompression of the nerve traversing the compartment might alleviate the symptoms (Rorabeck, 1984). It usually occurs in the upper or lower limb after an injury. During compartment syndrome there is decreased pressure due to the accumulation of necrotic debris and haemorrhage, especially haemorrhage to secondary fractures (Rorabeck, 1984). Acute compartment syndrome (ACS) of the lower extremity is a clinical condition that is seen fairly regularly in modern practice (Shagdan, 2010). Although pathophysiology of the disorder is well known to physicians who care for patients with musculoskeletal injuries, the diagnosis is often difficult to make (Shagdan, 2010). If left untreated, acute compartment syndrome can lead to more severe conditions including rhabdomyolysis
Rhabdomyolysis
Rhabdomyolysis is a condition in which damaged skeletal muscle tissue breaks down rapidly. Breakdown products of damaged muscle cells are released into the bloodstream; some of these, such as the protein myoglobin, are harmful to the kidneys and may lead to kidney failure...
and kidney failure potentially leading to death.
Subacute compartment syndrome
Subacute compartment syndrome, while not quite as much of an emergency, usually requires urgent surgical treatment similar to acute compartment syndrome.Chronic compartment syndrome
Chronic compartment syndrome in the lower leg can be treated conservatively or surgically. Conservative treatment includes rest, anti-inflammatories, and manual decompression. Elevation of the affected limb in patients with compartment syndrome is contraindicated, as this leads to decreased vascular perfusion of the affected region. Ideally, the affected limb should be positioned at the level of the heart. The use of devices that apply external pressure to the area, such as splints, casts, and tight wound dressings, should be avoided. In cases where symptoms persist, the condition can be treated by a surgical procedure, subcutaneous fasciotomy or open fasciotomy. Left untreated, chronic compartment syndrome can develop into the acute syndrome. A possible complication of surgical intervention for chronic compartment syndrome can be chronic venous insufficiency.Hyperbaric oxygen therapy has been suggested by case reports — though as of 2011 not proven in controlled randomized trials — to be an effective adjunctive therapy for crush injury, compartment syndrome, and other acute traumatic ischemias, by improving wound healing and reducing the need for repetitive surgery. The main treatment for compartment syndrome is surgery. There needs to be an incision in the skin so that the skin may be retracted back. Incisions are made in the affected muscle compartments so that they will decompress. This decompression will relieve the pressure on the venules and lymphatic vessels, and will increase bloodflow throughout the muscle.
Technology solutions for compartment syndrome involving continuous monitoring have also been proposed and tested.
Complications
Failure to relieve the pressure can result in necrosisNecrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
of tissue in that compartment, since capillary perfusion will fall leading to increasing hypoxia
Hypoxia (medical)
Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...
of those tissues. This can cause Volkmann's contracture
Volkmann's contracture
Volkmann's contracture, also known as Volkmann's ischaemic contracture, is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. It is more common in children. Passive extension of fingers is restricted and painful...
in affected limbs. As intercompartmental pressure rises during compartment syndrome, perfusion within the compartment is reduced leading to ischemia, which if left untreated results in necrosis of nerves and muscles of the compartment (Shears, 2006).
Further reading
- Floyd R. and Thompson C. Manual of Structural Kinesiology 17th Ed., McCrawHill. ISBN 978-0-07-337643-1
- Blackman, Paul G.. "A review of chronic exertional compartment syndrome in the lower leg." Medicine and Science in Sports and Exercise 32.3 (supp): S4-S10.
- Hamill, J and Knutzem KM. Biomechanical Basis of Human Movement, 3rd Ed. Lippincott Williams&Wilkins. ISBN: 978-0-7817-9128-1
- Leung, Y.F., Ip, S.P., Chung, O.M., Wai, Y.L., (2003, June). Unimuscular neuromuscular insult of the leg in partial anterior compartment syndrome in a patient with combined fractures. Hong Kong Medical Journal, 9.
- Rankin, E.A., Andrews, G. (1981, December). Anterior tibial compartmental syndrome: an unusual presentation. Journal of the National Medical Association, 73.
- Rorabeck, C.H., (1984, January). The treatment of compartment syndromes of the leg. Journal of Bone and Joint Surgery-British, 66-B. Retrieved from http://web.jbjs.org.uk/cgi/content/abstract/66-B/1/93
- Shadgan, B., et. al. (2010, October). Current thinking about acute compartment syndrome of the lower extremity, Canadian Journal of Surgery, 53.
- Shears, E., Porter, K. (2006). Acute compartment syndrome of the limb. Trauma, 8.
- Touliopolous, S., Hershman, E.B., (1999, March). Lower leg pain: diagnosis and treatment of compartment syndromes and other pain syndromes of the leg. Sports Medicine, 27.