Author:
Chester D.Shermer
Description
- Elevated tissue pressure in closed spaces that compromises blood flow through capillaries
- Normal tissue pressure is <10 mm Hg
- Capillary blood flow in a compartment is compromised at pressures >20 mm Hg
- Muscles and nerves can develop ischemic necrosis at pressures >30 mm Hg
- When distal pulses are diminished on exam, muscle necrosis is probably present
- The 4 compartments of the leg are most frequently involved, but compartment syndrome can occur in the arm, forearm, hand , foot, shoulder, buttocks, and thigh
Etiology
- Decreased compartment size: Circumferential cast, burn eschar, or military antishock trousers (MAST)
- Increased compartment contents: Compression of the compartment from edema or hematoma caused by direct trauma, fracture, overexertion of muscles, contrast extravasation, injection of recreational drugs, postischemic time, or limb compression during prolonged recumbency
ALERT |
- Keep the extremity at the level of the heart to promote arterial flow but not diminish venous return
- Do not use ice if compartment syndrome is suspected - it may compromise microcirculation
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Signs and Symptoms
- Severe, constant pain over the compartment that is disproportionate to extent of injury
- Pain increases with active contraction and passive stretching
- Muscle weakness
- Hypesthesia
- 6 P's: Pain, pressure, paresis, paresthesia, and pulses present
History
- Elicit above symptoms in proper clinical setting
- 6 P's
Physical Exam
- Tenderness of muscle compartment
- Assess motor and neurologic function
Diagnostic Tests & Interpretation
Imaging
Radiographs should be performed if fracture is suspected
Diagnostic Procedures/Surgery
- Measurement of compartment pressures with a system such as the Stryker IC pressure monitor system (Stryker Surgical, 2825 Airview Boulevard, Kalamazoo, MI 49002. www.stryker.com), using an 18G needle or continuous pressure monitoring with the attachment for an indwelling catheter
- Technique is as follows:
- Prep overlying skin with antiseptic solution
- Local anesthetic can be infiltrated into the SC tissue only, taking care not to inject intramuscularly
- The needle used for pressure measurements is advanced through the skin until a popping sensation is felt when the fascia is pierced
- 0.2 mL of saline is injected to clear the lumen of the needle, and the intracompartmental pressure measurement is then read
- To ascertain correct placement of the needle within the compartment, external pressure may be applied over the muscle compartment, or the muscles can be passively stretched to increase the intracompartmental pressure transiently; once these maneuvers are discontinued, the pressure should drop to baseline and stabilize
Differential Diagnosis
- Chronic compartment syndrome
- Fascial hernia
- Stress fracture
- Arterial occlusion
- Neurapraxia
- Deep venous thrombosis
- Cellulitis
- Osteomyelitis
- Tenosynovitis
- Synovitis
Initial Stabilization/Therapy
- Acutely injured extremities that are casted should have the cast univalved and spread and underlying cast padding should be cut
- Keep the extremity at the level of the heart
ED Treatment/Procedures
- Acute compartment syndrome is a surgical emergency
- Mainstay of treatment is fasciotomy, particularly for compartment pressures >30-40 mm Hg
Medication
- Medications are not helpful, including steroids or vasodilators, in the treatment of compartment syndrome
- Pain medication is essential after diagnosis is made or consultant evaluation is begun
First Line
IV narcotic analgesics may provide some relief, although the pain is frequently so severe that only decompression in the OR can provide relief
Second Line
Oral narcotic analgesics and nonsteroidal agents are of very little benefit acutely
Disposition
Admission Criteria
- Emergent orthopedic or surgical consultation for compartment pressures >30 mm Hg
- For compartment pressures >20 mm Hg but <30 mm Hg, surgical consultation should be sought and the patient admitted
- For compartment pressures between 15-20 mm Hg, serial measurement of pressures should be taken; if the patient cannot be relied on to return for repeat measurements, the patient should be admitted
Discharge Criteria
Compartment pressure <10-15 mm Hg: Patients should be given symptomatic treatment and instructed to return for increased pain, swelling, development of paresthesia
Issues for Referral
If the clinician suspects chronic compartment syndrome, then prompt referral to orthopedic surgeon is necessary. Direct communication is best to express your concerns
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- FarrD, SelesnickH. Chronic exertional compartment syndrome in a collegiate soccer player: A case report and literature review . Am J Orthop. 2008;37(7):374-377.
- MabeeJR. Compartment syndrome: A complication of acute extremity trauma . J Emerg Med. 1994;12(5):651-656.
- ReisND, BetterOS. Mechanical muscle-crush injury and acute muscle-crush compartment syndrome . J Bone Joint Surg Br. 2005;87(4):450-453.
- SahniV, GargD, GargS, et al. Unusual complications of heroin abuse: Transverse myelitis, rhabdomyolysis, compartment syndrome, and ARF . Clin Toxicol (Phila). 2008;46:153-155.
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