ACUTE COMPARTMENT SYNDROME

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, orMAST 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 pressuremeasurement
. Indicated in polytrauma, obtunded patient, orwith inconclusive
clinical diagnosis
. Direct measurement of involved compartments using needle
catheter such as a Stryker STIC catheter, WICK catheter, or
transducer fromarterial 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
. Posteriormedial incision – 2 cmposterior 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.