Compartment Syndrome Diagnosis and Treatment

Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Definition

• The muscles of the limbs are organized into closed anatomical compartments.

• These compartments are bounded by strong, relatively noncompliant fascial membranes.

• A compartment is defined as a closed space containing muscles, blood vessels, and nerves surrounded by fascia.

• Compartment syndrome occurs due to elevation of interstitial pressure within a closed osteofascial compartment, leading to microvascular compromise.

• Compartments with rigid fascial or osseous boundaries are most commonly involved, such as:

  • Anterior and deep posterior compartments of the leg

  • Volar compartment of the forearm

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Types of Compartment Syndrome

Based on the cause and duration of increased pressure:

1. Acute compartment syndrome (surgical emergency)

2. Chronic exertional compartment syndrome

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Anatomy of Compartments

Upper Limb

Arm

• Anterior compartment

• Posterior compartment

Forearm

• Dorsal compartment

• Superficial volar compartment

• Deep volar compartment

• Mobile wad

Hand

• Four dorsal interossei

• Three volar interossei

• Thenar compartment

• Hypothenar compartment

• Adductor compartment

• Mid-palm compartment

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Lower Limb

Thigh

• Anterior compartment

• Posterior compartment

• Medial compartment

Leg

• Anterior compartment

• Lateral compartment

• Superficial posterior compartment

• Deep posterior compartment

Foot

• Medial compartment

• Superficial compartment

• Lateral compartment

• Adductor compartment

• Four interossei compartments

• Calcaneal compartment

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Pathophysiology

• An insult to local tissue homeostasis leads to:

  • Increased intracompartmental pressure

  • Reduced capillary blood flow

  • Tissue ischemia

  • Cellular hypoxia and necrosis

• The Eaton and Green vicious cycle explains the progressive worsening of ischemia and edema.

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Etiology of Acute Compartment Syndrome

1. Decreased Compartment Size

• Tight bandages, dressings, or casts

• Burn eschar

• External compression such as prolonged limb positioning

• Military anti-shock garments or tourniquets

• Entrapment under heavy weights

• Tight closure of fascial defects

• Excessive traction

• Limb lengthening procedures

• Intramedullary nailing in neglected fractures or deformity correction

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2. Increased Compartment Content

• Fractures, both open and closed (most common cause)

• Crush injuries and blunt trauma

• Vigorous or prolonged exercise

• Animal bites and stings

• Hemorrhage or anticoagulant use

• Ruptured cysts such as Baker’s cyst

• Revascularization after ischemia

• Intravenous fluid extravasation

• High-pressure injections

• Intraosseous infusion in children

• Reaming during intramedullary nailing

• Use of fluid pumps during arthroscopy

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Clinical Evaluation: Characteristic Features

The classic clinical features include:

1. Pain out of proportion to injury

2. Paresthesia or hypoesthesia

3. Pallor

4. Poikilothermia

5. Pulselessness

6. Paralysis

• A seventh feature is raised intracompartmental pressure

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Pain

• Earliest and most important symptom

• Severe, deep, burning pain disproportionate to injury

• Exacerbated by passive stretching of involved muscles

• Pain may be absent in cases of nerve injury, anesthesia, or heavy analgesia

• Assessment is difficult in unconscious or sedated patients

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Paresthesia

• Often an early but unreliable symptom

• In anterior leg compartment syndrome, numbness between the first 2 toes may be the first sign

• Sensory testing includes:

  • Light touch

  • Pinprick

  • Two-point discrimination

• Decreased light touch sensation is the earliest and most reliable indicator

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Paralysis

• A late finding indicating irreversible muscle and nerve injury

• Paresis may appear earlier but is difficult to assess due to pain

• Presence of objective motor deficit indicates advanced disease

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Pallor and Pulselessness

• Rare findings

• Distal pulses are usually present

• Suggest associated vascular injury rather than isolated compartment syndrome

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Diagnosis

Diagnosis is based on:

• Clinical history

• Physical examination

• Measurement of intracompartmental pressure when required

• Intramuscular pH monitoring is rarely used

Important considerations:

• A single normal pressure reading does not exclude acute compartment syndrome

• Serial or continuous pressure monitoring is recommended in high-risk cases

Delta Pressure

• Defined as diastolic blood pressure minus compartment pressure

• A delta pressure less than 20 to 30 millimeters of mercury indicates need for fasciotomy

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Initial Management

• Remove constrictive dressings or casts

• Position limb at heart level

• Avoid limb elevation

• Correct hypotension and anemia

• Administer supplemental oxygen

• Role of mannitol remains unclear

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Definitive Management

Non-Operative

• Appropriate only for impending compartment syndrome

• Requires close serial clinical and pressure monitoring

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Operative Management

Fasciotomy

• Emergency surgical procedure

• Relieves compartment pressure

• Does not reverse existing tissue damage

• Indicated in:

  • Positive clinical findings

  • Compartment pressure greater than 30 millimeters of mercury

  • Delta pressure less than 20 to 30 millimeters of mercury

  • Progressive clinical deterioration

  • Unconscious or uncooperative patients with elevated pressures

  • Hand compartment pressures greater than 15 to 20 millimeters of mercury

Contraindication

• Missed compartment syndrome beyond 24 to 48 hours due to irreversible damage and high infection risk

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Principles of Fasciotomy

• Early diagnosis

• Long, extensile incisions

• Complete release of all involved compartments

• Preservation of neurovascular structures

• Debridement of nonviable tissue

• Timely wound coverage within 7 to 10 days

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Postoperative Care and Rehabilitation

• Leave wounds loosely packed

• Apply bulky dressing and splint in functional position

• Gradual wound closure using shoelace technique or negative pressure wound therapy

• Second-look surgery after 2 to 5 days

• Early initiation of range-of-motion exercises

• Skin grafting if required

• Limb immobilization for 3 to 5 days after grafting

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Complications

• Myonecrosis

• Nerve injury

• Volkmann ischemic contracture

• Reperfusion syndrome

• Infection

• Amputation

• Death

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Chronic Exertional Compartment Syndrome

Overview

• Also known as exertional or recurrent compartment syndrome

• Common in young athletes and military recruits

• Most frequently affects the lower limb

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Pathophysiology

• Exercise-induced muscle volume expansion

• Increased intramuscular pressure

• Reduced blood flow

• Ischemic pain and functional impairment

• Fascial hernia present in 15 to 40 percent of cases

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Clinical Features

• Exercise-induced pain

• Compartment tenderness

• Bilateral involvement is common

• Fascial hernia may be visible

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Diagnosis

• Intracompartmental pressure testing is the diagnostic standard:

  • Resting pressure of 15 millimeters of mercury or more

  • Pressure of 30 millimeters of mercury at 1 minute post-exercise

  • Pressure of 20 millimeters of mercury at 5 minutes post-exercise

  • Pressure greater than 25 millimeters of mercury at 15 minutes is a reliable cutoff

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Management

Non-Operative

• Analgesics

• Activity modification

• Physical therapy modalities

Operative

• Single incision fasciotomy

• Double mini-incision fasciotomy

• Double incision fasciotomy

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Complications of Chronic Compartment Syndrome Surgery

• Hemorrhage

• Skin breakdown

• Sensory changes

• Recurrence

• Infection

• Deep vein thrombosis

• Vascular or nerve injury

• Complex regional pain syndrome