Compartment syndrome

Compartment syndrome
A picture following surgery for compartment syndrome
Specialty Orthopedics
Symptoms Pain, numbness, pallor, decreased ability to move the affected limb[1]
Complications Acute: Volkmann's contracture[2]
Types Acute, chronic[1]
Causes Acute: Trauma (fracture, crush injury), following a period of poor blood flow[3][4]
Chronic: Repetitive exercise[1]
Diagnostic method Based on symptoms, compartment pressure[5][1]
Differential diagnosis Cellulitis, tendonitis, deep vein thrombosis, venous insufficiency[3]
Treatment Acute: Timely surgery[5]
Chronic: Physical therapy, surgery[1]

Compartment syndrome is a condition in which increased pressure within one of the body's compartments results in insufficient blood supply to tissue within that space.[6][7] There are two main types: acute and chronic.[6] The leg or arm is most commonly involved.[3]

Symptoms of acute compartment syndrome can include severe pain, poor pulses, decreased ability to move, numbness, or a pale color of the affected limb.[5] It is most commonly due to physical trauma such as a bone fracture or crush injury.[3] It can also occur after blood flow returns following a period of poor blood flow.[4] Diagnosis is generally based upon a person's symptoms.[5] Treatment is by surgery to open the compartment completed in a timely manner.[5] If not treated within six hours, permanent muscle or nerve damage can result.[5]

In chronic compartment syndrome, there is generally pain with exercise.[1] Other symptoms may include numbness.[1] Symptoms typically resolve with rest.[1] Common activities that trigger it include running and biking.[1] It does not generally result in permanent damage.[1] Other conditions that may present similarly include stress fractures and tendinitis.[1] Treatment may include physical therapy or—if that is not effective—surgery.[1]

Acute compartment syndrome occurs in about 3% of those who have a midshaft fracture of the forearm.[8] Rates in other areas and for chronic cases are unknown.[8][9] The condition more often occurs in those under the age of 35 and in males.[3] Compartment syndrome was first described in 1881 by Richard von Volkmann.[5] Untreated, acute compartment syndrome can result in Volkmann's contracture.[2]

Signs and symptoms

Acute compartment syndrome (ACS) can develop after a severe crush injury and rarely after a relatively minor injury. The legs and the forearms are the most frequent sites affected by compartment syndrome. Other areas of the body such as thigh, buttock, hand, and foot can also be affected.[10]

Acute

Acute compartment syndrome with blister formation in the arm of a child

There are five characteristic signs and symptoms related to acute compartment syndrome: pain, paraesthesia (reduced sensation), paralysis, pallor, and pulselessness.[11] Pain and paresthesia are the early symptoms of compartment syndrome.[10]

  • Pain - The pain would be disproportionate to the findings of the physical examination and is not relieved by analgesia up to and including morphine. The pain is aggravated by passively stretching the muscle group within the compartment. However, such pain may disappear in the late stages of the compartment syndrome.[10] The role of local anaesthesia in delaying the diagnosis of compartment is still being debated.[10]
  • Paresthesia (altered sensation) - A person may complain of "pins & needles", numbness, and a tingling sensation. This may progress to loss of sensation (anesthesia) if no intervention has been made.[10]
  • Paralysis - Paralysis of the limb is a rare, late finding. It may indicate both a nerve or muscular lesion.[10]
  • Pallor and pulselessness - A lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often well below arterial pressures. Absent pulses only occurs when there is arterial injury or during the late stages of the compartment syndrome.[11]

The limb with compartment syndrome is often associated with a firm, wooden feeling on deep palpation.[11]

Chronic

The symptoms of chronic exertional compartment syndrome (CECS) are brought on by exercise and consist of a sensation of extreme tightness in the affected muscles followed by a painful burning sensation if exercise is continued. After exercise is ceased, the pressure in the compartment will decrease within a few minutes, relieving painful symptoms. Symptoms will occur at a certain threshold of exercise which varies from person to person but is rather consistent for a given individual and can range anywhere from 30 seconds of running to about 10–15 minutes of running. CECS most commonly occurs in the lower leg, with the anterior compartment being the most frequently affected compartment.[12] Foot drop is a common symptom of CECS.[13]

Complications

Failure to relieve the pressure can result in necrosis of tissue in that compartment, since capillary perfusion will fall leading to increasing oxygen deprivation of those tissues. This can cause Volkmann's contracture in affected limbs. As intercompartmental pressure rises during compartment syndrome, perfusion within the compartment is reduced leading to ischemia, which if left untreated, results in necrosis of nerves and muscles of the compartment (Shears, 2006). Rhabdomyolysis and subsequent renal failure are also possible complications.

Causes

Acute

The most common cause of acute compartment syndrome (ACS) are fractures, which account for 69% to 75% of the cases. Leg compartment syndrome is found in 2 to 9% of the tibial fractures. There is no difference in incidences of compartment syndrome between open and closed fractures. Rhabdomyolysis is associated with 23% of the cases. In this case, inflammation and soft tissue swellings would determine the rise of intra-compartmental pressure. Injury to blood vessels such as popliteal artery have a high incidence of compartment syndrome by reducing blood supply to soft tissues. Such reduction in blood supply can cause a series of inflammatory reactions that promote the swelling of the soft tissues. Such inflammation can be further worsened by reperfusion therapy.[10] Because the fascia layer that defines the compartment of the limbs does not stretch, a small amount of bleeding into the compartment, or swelling of the muscles within the compartment, can cause the pressure to rise greatly. Other causes such as intravenous drug injection, casts, prolonged limb compression, crush injuries and eschars from burns can also cause compartment syndrome.[14][15] Rare causes of compartment syndrome are: gluteal compartment syndrome due to injury to superior gluteal artery, and those with anticoagulant therapy has increase risk of bleeding into a closed compartment.[10]

Abdominal compartment syndrome occurs when the intra-abdominal pressure exceeds 20 mmHg and abdominal perfusion pressure is less than 60 mmHg, associated with organ dysfunction and organ failures. There are three causes of abdominal compartment syndrome: primary (haemorrhage and organ odema), secondary (vigorous fluid replacement which causes formation of ascites and rise in intra-abdominal pressure), and recurrent (compartment syndrome recurred after the treatment of secondary compartment syndrome).[16]

Chronic

When compartment syndrome is caused by repetitive use of the muscles, it is known as chronic compartment syndrome (CCS).[17][18] This is usually not an emergency, but the loss of circulation can cause temporary or permanent damage to nearby nerves and muscles.

Complementary to chronic compartment syndrome is another subset known as chronic exertional compartment syndrome CECS, often called exercise induced compartment syndrome EICS.[19] CECS of the leg is a condition caused by exercise which results in increased tissue pressure within a limited fibro-osseous compartment – muscle size may increase by up to 20% during exercise.[20] When this happens, pressure builds up in the tissues and muscles causing tissue ischemia.[20] An increase in muscle weight will reduce the compartment volume of the surrounding fascial borders and result in an increase of intracompartmental pressure.[19] An increase in the pressure of the tissue can cause fluid to exude into the small spaces between the tissue known as interstitial space, leading to a disruption of the micro-circulation of the leg.[19] This condition occurs commonly in the lower leg and various other locations within the body, such as the foot or forearm. This is commonly seen in athletes who train rigorously in activities that involve constant repetitive actions or motions.[19] In athletic popular culture there is a catchphrase, "Feel the burn," which references these conditions as something to strive for when training, weightlifting or otherwise working out. They are not understood as symptoms.[21] The symptoms involve numbness or a tingling sensation in the area most affected. Other signs and symptoms include pain described as aching, tightening, cramping, sharp, or stabbing.[19] This pain can occur for months, and in some cases over a period of years, and may be relieved by rest.[19] It also includes moderate weakness that can be a noticeable factor in the affected region. Chronic exertional compartment syndrome most commonly affects the anterior compartment of the leg, this can lead to problems with dorsiflexion of the ankle and the toes.[22] The symptoms of CECS are often confused with more common injuries like shin splints and spinal stenosis.[22] Treatment for chronic exertional compartment syndrome includes decreasing or subsiding exercising and activities, or cross training for athletes.[19] In cases with severe intracompartmental pressures surgical treatment, a fasciotomy, is necessary.

Pathophysiology

In a normal human body, blood flow from the artery to vein requires a pressure gradient. When this pressure gradient is diminished, blood flow from the artery to the vein is reduced. This causes excessive fluid to go out from the capillary wall into spaces between the soft tissues cells, causing oedema and rise in intra-compartmental pressure. Swelling of the soft tissues compresses the blood and lymphatic vessels further, causing more fluid to enter the intercellular spaces, leading to more compression, eventually leading to lack of oxygen in the soft tissues (tissue ischaemia) and tissue death (necrosis). Tingling and abnormal sensation (paraesthesia) can begin as early as 30 minutes from the start of tissue ischemia and permanent damage can occur as early as 12 hours post onset.[10]

Diagnosis

Compartment syndrome is a clinical diagnosis. Apart from the typical signs and symptoms, measurement of intra-compartmental pressure is also important for diagnosis. A transducer connected to a catheter is inserted 5 cm into the zone of injury.[11] A pressure higher than 30 mmHg of the diastolic pressure in conscious or unconscious person is associated with compartment syndrome; and fasciotomy is indicated. For those with hypotension, a pressure of 20 mmHg higher than the intra-compartmental pressure is associated with compartmental syndrome.[10]

Most commonly compartment syndrome is diagnosed through a diagnosis of its underlying cause and not the condition itself. According to Blackman one of the tools to diagnose compartment syndrome is X-ray to show a tibia/fibula fracture, which when combined with numbness of the extremities is enough to confirm the presence of compartment syndrome.[23]

Treatment

Acute

Any orthopedic casts or dressing applied on the affected limb should be removed. Cutting of cast will reduce the intra-compartmental pressure by 65%, followed by 10 to 20% pressure reduction once padding is cut. After the cast removal, the limb should be placed at the heart level for adequate perfusion. The vital signs of the patient should be closely monitored. If the clinical condition does not improve, then fasciotomy is indicated to decompress the compartments. An incision large enough to decompress all the compartments is necessary. Such procedure is performed inside an operating theatre under general or local anaesthesia.[10] However, the timing of wound closure is still debatable. Wound edges need to be debrided and irrigated before closure. Usually, wound closure would be done seven days after fasciotomy.[10]

Chronic

Chronic compartment syndrome in the lower leg can be treated conservatively or surgically. Conservative treatment includes rest, anti-inflammatories, and manual decompression. Elevation of the affected limb in patients with compartment syndrome is contraindicated, as this leads to decreased vascular perfusion of the affected region. Ideally, the affected limb should be positioned at the level of the heart. The use of devices that apply external pressure to the area, such as splints, casts, and tight wound dressings, should be avoided.[24] If symptoms persist after conservative treatment or if an individual does not wish to cease engaging in the physical activities which bring on symptoms, compartment syndrome can be treated by a surgery known as a fasciotomy. Surgery is the most effective treatment for compartment syndrome. Incisions are made in the affected muscle compartments so that they will decompress. This decompression will relieve the pressure on the venules and lymphatic vessels, and will increase bloodflow throughout the muscle. Left untreated, chronic compartment syndrome can develop into the acute syndrome and lead to permanent muscle and nerve damage.

A military study conducted in 2012 found that teaching individuals with lower leg chronic exertional compartment syndrome to change their running stride to a forefoot running technique abated symptoms.[25] Follow up studies are needed to confirm the finding of this study.

Hyperbaric oxygen therapy has been suggested by case reports – though as of 2011 not proven in controlled randomized trials – to be an effective adjunctive therapy for crush injury, compartment syndrome, and other acute traumatic ischemias, by improving wound healing and reducing the need for repetitive surgery.[26][27]

Prognosis

A mortality rate of 47% has been reported for acute compartment syndrome of the thigh. According to one study the rate of fasciotomy varied from 2% to 24%.[10]

Epidemiology

The annual incidence of acute compartment syndrome is 1 to 7.3 per 100,000. Men are ten times more likely than women to develop ACS. Mean age for ACS in men is 30 years. Meanwhile for women, the mean age is 44 years.[10]

Notable cases

PBS science correspondent Miles O'Brien had a compartment syndrome and had to have his left arm amputated.[28]

NFL Player Rahim Moore.[29]

Kara Goucher, professional long distance runner.[30]

Tessa Virtue, Olympic ice dancer.[31]

See also

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 "Compartment Syndrome-OrthoInfo - AAOS". www.orthoinfo.org. October 2009. Archived from the original on 14 March 2017. Retrieved 29 July 2017.
  2. 1 2 El-Darouti MA (2013). Challenging Cases in Dermatology. Springer Science & Business Media. p. 145. ISBN 9781447142492. Archived from the original on 2017-07-29.
  3. 1 2 3 4 5 Ferri FF (2017). Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 317. ISBN 9780323529570. Archived from the original on 2017-07-29.
  4. 1 2 Schmidt AH (July 2016). "Acute Compartment Syndrome". The Orthopedic Clinics of North America. 47 (3): 517–25. doi:10.1016/j.ocl.2016.02.001. PMID 27241376.
  5. 1 2 3 4 5 6 7 Donaldson J, Haddad B, Khan WS (2014). "The pathophysiology, diagnosis and current management of acute compartment syndrome". The Open Orthopaedics Journal. 8: 185–93. doi:10.2174/1874325001408010185. PMC 4110398. PMID 25067973.
  6. 1 2 "Compartment Syndrome - National Library of Medicine". PubMed Health. Archived from the original on 10 September 2017. Retrieved 25 July 2017.
  7. ↑ Peitzman AB, Rhodes M, Schwab CW (2008). The Trauma Manual: Trauma and Acute Care Surgery. Lippincott Williams & Wilkins. p. 349. ISBN 9780781762755. Archived from the original on 2017-07-29.
  8. 1 2 Bucholz RW (2012). Rockwood and Green's Fractures in Adults: Two Volumes Plus Integrated Content Website (Rockwood, Green, and Wilkins' Fractures). Lippincott Williams & Wilkins. p. 691. ISBN 9781451161441. Archived from the original on 2017-07-29.
  9. ↑ Miller MD, Wiesel SW (2012). Operative Techniques in Sports Medicine Surgery. Lippincott Williams & Wilkins. p. 437. ISBN 9781451124903. Archived from the original on 2017-07-29.
  10. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Via AG, Oliva F, Spoliti M, Maffulli N (2015). "Acute compartment syndrome". Muscles, Ligaments and Tendons Journal. 5 (1): 18–22. PMC 4396671. PMID 25878982.
  11. 1 2 3 4 Donaldson J, Haddad B, Khan WS (27 June 2014). "The pathophysiology, diagnosis and current management of acute compartment syndrome". The Open Orthopaedics Journal. 8: 185–93. doi:10.2174/1874325001408010185. PMC 4110398. PMID 25067973.
  12. ↑ Bong MR, Polatsch DB, Jazrawi LM, Rokito AS (2005). "Chronic exertional compartment syndrome: diagnosis and management" (PDF). Bulletin. 62 (3–4): 77–84. PMID 16022217.
  13. ↑ Awbrey B, Shingo T. "Chronic Exercise-Induced Compartment Syndrome of the Leg". Harvard Orthopaedic Journal. 1 (7). Archived from the original on 24 September 2015. Retrieved 16 October 2014.
  14. ↑ Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ (December 2007). "Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective". The American Surgeon. 73 (12): 1199–209. PMID 18186372.
  15. ↑ Salcido R, Lepre SJ (October 2007). "Compartment syndrome: wound care considerations". Advances in Skin & Wound Care. 20 (10): 559–65, quiz 566-7. doi:10.1097/01.ASW.0000294758.82178.45. PMID 17906430.
  16. ↑ Maerz L, Kaplan LJ (April 2008). "Abdominal compartment syndrome". Critical Care Medicine. 36 (4 Suppl): S212–5. doi:10.1097/CCM.0b013e318168e333. PMID 18382196.
  17. ↑ Wanich T, Hodgkins C, Columbier JA, Muraski E, Kennedy JG (December 2007). "Cycling injuries of the lower extremity". The Journal of the American Academy of Orthopaedic Surgeons. 15 (12): 748–56. PMID 18063715.
  18. ↑ Verleisdonk EJ (October 2002). "The exertional compartment syndrome: A review of the literature". Ortopedia, Traumatologia, Rehabilitacja. 4 (5): 626–31. PMID 17992173.
  19. 1 2 3 4 5 6 7 Cetinus E, Uzel M, Bilgiç E, Karaoguz A, Herdem M (April 2004). "Exercise induced compartment syndrome in a professional footballer". British Journal of Sports Medicine. 38 (2): 227–9. doi:10.1136/bjsm.2003.004630. PMC 1724759. PMID 15039267.
  20. 1 2 Touliopolous S, Hershman EB (March 1999). "Lower leg pain. Diagnosis and treatment of compartment syndromes and other pain syndromes of the leg". Sports Medicine. 27 (3): 193–204. doi:10.2165/00007256-199927030-00005. PMID 10222542.
  21. ↑ "Archived copy". Archived from the original on 2017-01-15. Retrieved 2017-01-23.
  22. 1 2 Furcolo K (2 December 2010). "Exercise Induced Compartment Syndrome". Foundrysportsmedicine.com. Archived from the original on 2014-04-21. Retrieved 2014-03-08.
  23. ↑ Blackman PG (March 2000). "A review of chronic exertional compartment syndrome in the lower leg". Medicine and Science in Sports and Exercise. 32 (3 Suppl): S4–10. doi:10.1249/00005768-200003001-00002. PMID 10730989.
  24. ↑ Meyer RS, White KK, Smith JM, Groppo ER, Mubarak SJ, Hargens AR (October 2002). "Intramuscular and blood pressures in legs positioned in the hemilithotomy position : clarification of risk factors for well-leg acute compartment syndrome". The Journal of Bone and Joint Surgery. American Volume. 84-A (10): 1829–35. PMID 12377915.
  25. ↑ Diebal AR, Gregory R, Alitz C, Gerber JP (May 2012). "Forefoot running improves pain and disability associated with chronic exertional compartment syndrome". The American Journal of Sports Medicine. 40 (5): 1060–7. doi:10.1177/0363546512439182. PMID 22427621.
  26. ↑ Undersea and Hyperbaric Medical Society. "Crush Injury, Compartment syndrome, and other Acute Traumatic Ischemias". Archived from the original on 2008-05-08.
  27. ↑ Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P (August 1996). "Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial". The Journal of Trauma. 41 (2): 333–9. doi:10.1097/00005373-199608000-00023. PMID 8760546.
  28. ↑ "PBS science correspondent Miles O'Brien recounts amputation". Fox News. 2014-02-25. Archived from the original on 2014-03-09. Retrieved 2014-03-08.
  29. ↑ "There Are Some Things Rahim Moore Doesn't Want to Remember". Sports Illustrated. 2014-05-28. Archived from the original on 2014-09-10. Retrieved 2014-09-09.
  30. ↑ "Ask Us Anything: Adam and Kara Goucher". Runner's World. Runner's World Magazine. Retrieved October 14, 2015.
  31. ↑ "Canada's Virtue sidelined by surgery". CBC Sports. CBC Sports. Retrieved October 12, 2010.
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