Introduction |
- Devastating condition where an osseofascial compartment pressure rises to a level that decreases perfusion
- may lead to irreversible muscle and nerve damage
- Epidemiology
- location
- compartment syndrome may occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
- leg (details below)
- forearm
- hand
- foot
- thigh
- buttock
- shoulder
- paraspinous muscles
- Pathophysiology
- etiology
- trauma
- fractures (69% of cases)
- crush injuries
- contusions
- gunshot wounds
- tight casts, dressings, or external wrappings
- extravasation of IV infusion
- burns
- postischemic swelling
- bleeding disorders
- arterial injury
- pathoanatomy
- cascade of events includes
- local trauma and soft tissue destruction>
- bleeding and edema >
- increased interstitial pressure >
- vascular occlusion >
- myoneural ischemia
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Anatomy |
- 4 compartments of the leg
- anterior compartment
- function
- dorsiflexion of foot and ankle
- muscles
- tibialis anterior
- extensor hallucis longus
- extensor digitorum longus
- peroneus tertius
- lateral compartment
- function
- plantarflexion and eversion of foot
- muscles
- peroneus longus
- peroneus brevis
- isolated lateral compartment syndrome would only affect superficial peroneal nerve
- deep posterior compartment
- function
- plantarflexion and inversion of foot
- muscles
- tibialis posterior
- flexor digitorum longus
- flexor hallucis longus
- superficial posterior compartment
- function
- mainly plantarflexion of foot and ankle
- muscles
- gastrocnemius
- soleus
- plantaris
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Presentation |
- Symptoms
- pain out of proportion to clinical situation is usually first symptom
- may be absent in cases of nerve damage
- pain is difficult to assess in a polytrauma patient and impossible to assess in a sedated patient
- difficult to assess in children (unable to verbalize)
- Physical exam
- pain w/ passive stretch
- is most sensitive finding prior to onset of ischemia
- paresthesia and hypoesthesia
- indicative of nerve ischemia in affected compartment
- paralysis
- late finding
- full recovery is rare in this case
- palpable swelling
- peripheral pulses absent
- late finding
- amputation usually inevitable in this case
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Imaging |
- Radiographs
- obtain to rule-out fracture
|
Studies |
- Compartment pressure measurements
- indications
- polytrauma patients
- patient not alert/unreliable
- inconclusive physical exam findings
- relative contraindication
- unequivocally positive clinical findings should prompt emergent operative intervention without need for compartment measurements
- technique
- should be performed within 5cm of fracture site
- anterior compartment
- entry point
- 1cm lateral to anterior border of tibia within 5cm of fracture site if possible
- needle should be perpendicular to skin
- deep posterior compartment
- entry point
- just posterior to the medial border of tibia
- advance needle perpendicular to skin towards fibula
- lateral compartment
- entry point
- just anterior to the posterior border of fibula
- superficial posterior
- entry point
- middle of calf within 5 cm of fracture site if possible
- Diagnosis
- based primarily on physical exam in patient with intact mental status
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Treatment |
- Nonoperative
- observation
- indications
- diastolic differential pressure (delta p) is > 30
- presentation not consistent with compartment syndrome
- bi-valving the cast and loosening circumferential dressings
- indications
- initial treatment for swelling or pain that is NOT compartment syndrome
- splinting the ankle between neutral and resting plantar flexion (37 deg) can also decrease intracompartmental pressures
- hyperbaric oxygen therapy
- works by increasing the oxygen diffusion gradient
- Operative
- emergent fasciotomy of all four compartments
- indications
- clinical presentation consistent with compartment syndrome
- compartment pressures within 30 mm Hg of diastolic blood pressure (delta p)
- intraoperatively, diastolic blood pressure may be decreased from anesthesia
- must compare intra-operative measurement to pre-operative diastolic pressure
- attempt to restore systemic blood pressure prior to measurement
- contraindications
- missed compartment syndrome
- Special considerations
- pediatrics
- children are unable to verbalize feelings
- if suspicion, then perform compartment pressure measurement under sedation
- hemophiliacs
- give Factor VIII replacement before measuring compartment pressures
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Techniques |
- Emergent fasciotomy of all four compartments
- dual medial-lateral incision
- approach
- two 15-18cm vertical incisions separated by 8cm skin bridge
- anterolateral incision
- posteromedial incision
- technique
- anterolateral incision
- identify and protect the superficial peroneal nerve
- fasciotomy of anterior compartment performed 1cm in front of intermuscular septum
- fasciotomy of lateral compartment performed 1cm behind intermuscular septum
- posteromedial incision
- protect saphenous vein and nerve
- incise superficial posterior compartment
- detach soleal bridge from back of tibia to adequately decompress deep posterior compartment
- post-operative
- dressing changes followed by delayed primary closure or skin grafting at 3-7 days post decompression
- pros
- easy to perform
- excellent exposure
- cons
- single lateral incision
- approach
- single lateral incision from head of fibula to ankle along line of fibula
- technique
- identify superficial peroneal nerve
- perform anterior compartment fasciotomy 1cm anterior to the intermuscular septum
- perform lateral compartment fasciotomy 1cm posterior to the intermuscular septum
- identify and perform fasciotomy on superficial posterior compartment
- enter interval between superficial posterior and lateral compartment
- reach deep posterior compartment by following interosseous membrane from the posterior aspect of fibula and releasing compartment from this membrane
- common peroneal nerve at risk with proximal dissection
- pros
- cons
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