- Clinical science
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 which 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.
|The etiology of compartment syndrome|
External compressing forces
Internal expanding forces
- Acute compartment syndrome: predominantly trauma-induced; a surgical emergency!
- Chronic compartment syndrome: also known as exertional compartment syndrome; usually not a medical emergency
- External or internal forces as initiating event → increased compartment pressure → decreased tissue perfusion → lower oxygen supply to muscles → irreversible tissue damage to muscles and nerves after 4–6 hours of ischemia
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
Typically presents with a rapid progression of symptoms.
- 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.
- Muscle weakness to paralysis
- Absent (or weak) distal pulses
- Cold peripheries
- Pallor or cyanosis
- Worsened pain and swelling
6 P's of acute limb ischemia: Pain, Pallor, Paresthesias, Poikilothermia, Pulselessness, and Paralysis!
Chronic compartment syndrome
- Pain exacerbated by exercise and relieved with rest
Arterial pulse is usually still palpable; pulselessness is a sign of very severe compartment syndrome!
Anterior compartment syndrome of the lower leg
- Most common type of acute compartment syndrome
- Motor: toe dorsiflexion weakness
- Sensory: loss of sensation/paresthesia in the nerve territory
- Treatment: surgery (dermato-fasciotomy)
- Chronic: peritoneal dialysis, morbid obesity, intra-abdominal mass
- Pathophysiology: ↑ intra-abdominal pressure → organ dysfunction
- Clinical features: may develop within hours or over days
Compartment pressure measurement is necessary to confirm the diagnosis. Further laboratory tests are unnecessary but should be performed in trauma-related compartment syndrome to assess for rhabdomyolysis. Imaging may be useful to identify an underlying etiology.
Compartment pressures (initial and confirmatory test): measurement of tissue pressure with a manometer and calculation of delta pressures (delta pressure = diastolic - (compartment) tissue pressure)
- Delta pressure in manifest compartment syndrome: ≤ 30 mm Hg
- Laboratory tests specific for rhabdomyolysis (e.g., creatine phosphokinase (CPK), renal function tests)
- Doppler ultrasound
- Pulse oximetry: not diagnostic but can help identify limb hypoperfusion
- Deep vein thrombosis
- Acute limb ischemia
- Rhabdomyolysis (often also a complication of compartment syndrome)
- Peripheral artery disease
|Acute compartment syndrome|| || || || |
| || || || |
| || || |
| || |
The differential diagnoses listed here are not exhaustive.
Surgical treatment: required for all cases of acute compartment syndrome!
- Also indicated if conservative treatment fails in chronic compartment syndrome.
- Fasciotomy (tissue and fascia incisions): relieves the pressure, thus restoring perfusion
- Fibulectomy: if fasciotomy fails; to decompress all compartments of the lower leg
- Escharotomy: In the case of circumferential compression by a burn eschar
- Last resort: amputation
- Indicated as perioperative care
- May be considered as sole treatment for chronic compartment syndrome
- Eliminate any underlying cause, e.g., 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; if in doubt, proceed with early surgical treatment!
- Correct any fluid imbalances
- Supplemental oxygen
Elevated positioning may worsen ischemia by reducing blood flow!
Acute compartment syndrome is a surgical emergency and requires an early fasciotomy!
- Muscle and soft tissue necrosis with a higher risk of infection
- Nerve lesions (esp. the tibial nerve and peroneal nerve) with sensory and motor deficits or paralysis
- Fracture malalignment
- Rhabdomyolysis with potential Crush syndrome
- Muscle contractures
Rebound compartment syndrome
- Occurs 6–12 hours after surgical reperfusion
- Etiology: increased capillary permeability and edema, often due to insufficient fasciotomy incisions
- Permanent flexion contracture due to shortening of forearm muscles (“claw-like deformity” of the hand, fingers, and wrist)
- Direct complication of insufficient treatment or undiagnosed compartment syndrome
We list the most important complications. The selection is not exhaustive.
The prognosis depends on the amount of time that has elapsed prior to performing the fasciotomy:
- ≤ 6 h: almost complete recovery
- 6–12 h: first necroses; normal limb function returns in 68% of cases
- ≥ 12 h: necroses; normal limb function returns in 8% of cases