• Clinical science

Compartment syndrome

Summary

Compartment syndrome is a condition in which increased pressure within a muscle compartment (containing nerves and vasculature, enclosed by unyielding fascia) leads to impaired tissue perfusion. It most commonly affects the lower legs, but can also occur in other parts of the extremities or the abdomen. Compartment syndrome may be acute (e.g., after trauma) or chronic (e.g., collectively excessive training in athletes). Acute compartment syndrome is a surgical emergency that initially presents with rapidly progressive pain, paresthesia, and pallor. Pronounced neurological symptoms with motor deficits, absent pulses, and poikilothermia occur later on and indicate irreversible damage. This diagnosis should be suspected in the presence of typical clinical findings and then confirmed via measurement of compartment pressures. Acute compartment syndrome requires early fasciotomy (an incision through the fascia) within six hours of onset to prevent severe ischemic necrosis. Chronic compartment syndrome is also often associated with pain; it can be exacerbated by exercise and relieved by rest, and is usually managed with conservative treatment. The prognosis of compartment syndrome is generally good with early and appropriate management.

Etiology

The etiology of compartment syndrome

External compressing forces

Internal expanding forces

Trauma-related
  • Burn eschars
  • Constrictive bandage/cast

Non-traumatic

  • Incorrect positioning limbs (e.g., immobile patient)

Peripheral circulation is reduced in polytrauma patients with shock. Therefore, increased compartment pressure in polytrauma patients is associated with an early, high risk of muscle ischemia.

Classification

Pathophysiology

External or internal forces as initiating event → increased compartment pressure obstruction of venous outflow and collapse of arterioles→ decreased tissue perfusion lower oxygen supply to muscles → irreversible tissue damage (necrosis) to muscles and nerves after 4–6 hours of ischemia

Clinical features

Compartment syndrome may occur in any enclosed muscle compartment inside the body. The most common sites are the lower legs and arms. Less common sites include the feet, hands, thighs, and gluteal region.

Acute compartment syndrome (ACS)

Typically presents with a rapid progression of symptoms

  • Early presentation
    • Pain
      • Often out of proportion to the extent of injury
      • Worse with passive stretching or extension of muscles
      • Very tight, wood-like muscles that are extremely tender to touch
    • Paresthesia (e.g., pins and needles)
    • Soft tissue swelling
    • Initially, peripheral circulation and distal pulses are maintained.
  • Late presentation
    • Worsened pain and swelling
    • Muscle weakness to paralysis
    • Cold peripheries
    • Pallor or cyanosis (uncommon)
    • Absent (or weak) distal pulses

6 P's of acute limb ischemia: Pain, Pallor, Paresthesias, Poikilothermia, Pulselessness, and Paralysis

Arterial pulse is usually still palpable; pulselessness is a sign of very severe compartment syndrome.

Chronic compartment syndrome

  • More common in young athletes and runners
  • Usually affects the lower legs
  • Muscle pain, weakness, and swelling exacerbated by exercise and relieved with rest
  • Paresthesia and numbness may occur.

Subtypes and variants

Anterior compartment syndrome of the lower leg

Abdominal compartment syndrome [1]

Diagnostics

Diagnosis of acute compartment syndrome is primarily clinical. [2][3]

Differential diagnoses

Differential diagnoses of compartment syndrome
Features Acute compartment syndrome Deep vein thrombosis Acute limb ischemia Rhabdomyolysis
History
  • Traumatic or non-traumatic
  • Immobility
  • Surgery
  • Pregnancy
  • Clotting disorder
Clinical features
  • Deep pain out of proportion to the injury
  • 6 P's (See “Clinical features” above.)
  • Often asymptomatic
  • Nonspecific pain and calf swelling
  • Acute onset (embolism) or subacute onset (arterial thrombosis)
  • 6 P's (See “Clinical features” above.)
  • Myalgia
  • Generalized weakness
  • Darkened urine (red to brown)
Diagnosis
  • Delta pressure ≤ 30 mm Hg
Treatment
  • Surgical and supportive treatment
  • Anticoagulation
  • Revascularization (interventional or surgical)
  • IV fluid administration

Others

The differential diagnoses listed here are not exhaustive.

Treatment

Surgical treatment [3]

Supportive treatment [3]

  • Indicated as perioperative care
  • May be considered as sole treatment for chronic compartment syndrome
  • Eliminate any underlying cause, i.e., remove restrictive cast/dressing
  • Cooling and positioning of the limb at heart level to relieve pressure
  • Close monitoring with frequent examination of the affected limb
  • Correct any fluid imbalances
  • Supplemental oxygen
  • Analgesia

Elevated positioning may worsen ischemia by reducing blood flow.

Acute compartment syndrome is a surgical emergency and requires an early fasciotomy.

Complications

We list the most important complications. The selection is not exhaustive.

Prognosis

The prognosis depends on the amount of time that has elapsed prior to performing the fasciotomy: [3]

  • ≤ 4–6 h: almost complete recovery
  • 6–12 h: first necroses
  • ≥ 12 h: necroses; little or no return of function
  • 1. Kirkpatrick AW, Roberts DJ, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013; 39(7): pp. 1190–1206. doi: 10.1007/s00134-013-2906-z.
  • 2. McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. The Estimated Sensitivity and Specificity of Compartment Pressure Monitoring for Acute Compartment Syndrome. J Bone Joint Surg. 2013; 95(8): pp. 673–677. doi: 10.2106/jbjs.k.01731.
  • 3. Taylor RM, Sullivan MP, Mehta S. Acute compartment syndrome: obtaining diagnosis, providing treatment, and minimizing medicolegal risk. Current Reviews in Musculoskeletal Medicine. 2012; 5(3): pp. 206–213. doi: 10.1007/s12178-012-9126-y.
last updated 11/03/2020
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