Extremity Compartment Syndrome

Epidemiology

  • This patient has developed rhabdomyolysis and a compartment syndrome from severe cocaine-induced hyperthermia, and a fasciotomy is indicated (thus, option A is a true statement). Compartment syndrome is due to increased interstitial pressures in a fixed fascial compartment resulting in compromised capillary perfusion and neuromuscular function, usually due to edema from tissue injury, bleeding, and/or ischemia. This syndrome most commonly develops in the distal lower extremities due to the relatively noncompliant fascial compartments in this area. Compartment syndrome is associated with ischemia, fractures, burns, crush injury, marching, snake bites, medical antishock trouser (MAST) use, malignant or severe hyperthermia, seizures, electrical injury, bleeding into an extremity, dysfunction of an intermittent compression boot, a cast, or the prolonged lithotomy position. In a patient who is alert, typical signs and symptoms include severe pain (out of proportion to physical findings early on, so option E is true) and hypoesthesia of the affected extremity late in the course. Physical examination reveals a tense, tender extremity.

  • Examinations of peripheral pulses are rarely helpful in this diagnosis as they are often intact until a very late stage of injury (thus, option C is true). In a nonsedated patient, pain with passive flexion of the foot is an important finding. The most common method of diagnosis and monitoring is measurement of compartment pressures. Normal values are 0 mm Hg. Patients with compartment pressures less than 30 mm Hg are unlikely to have a clinically significant compartment syndrome resulting in neuromuscular damage. However, when pressures exceed 30 to 35 mm Hg (option B), fasciotomy is indicated. Patients with pressures above 50 to 60 mm Hg nearly always develop significant dysfunction. Some surgeons use a gradient between the diastolic arterial pressure and the compartment pressures of less than 10 to 30 mm Hg as indicative of compartment syndrome. Other compatible findings in patients with compartment syndrome are related to rhabdomyolysis including creatine kinase elevations, hyperkalemia, renal failure, hyperphosphatemia, heme present on urine dipstick without red blood cells on microscopic examination, and myoglobinuria. Arteriography is important in the diagnosis of peripheral arterial emboli and thrombus but is not useful in the diagnosis of the compartment syndrome (thus, choice D is the only incorrect statement).


Etiology

  • Acute Limb Ischemia (see Acute Limb Ischemia, [[Acute Limb Ischemia]]): due to increased fluid content of muscle which occurs following limb reperfusion
  • Androgen Abuse (see Androgens, [[Androgens]]): due to muscle hypertrophy
  • Attempted Cannulation of Vein/Artery in Setting of Coagulopathy
  • Burns (see Burns, [[Burns]])
  • ObtundationComa with Limb Compression (see Obtundation-Coma, [[Obtundation-Coma]])
    • Alcohol Intoxication
    • Drug Intoxication
  • Deep Venous Thrombosis (DVT)
  • Drug Extravasation: pain/edema from extravasation alone needs to be differentiated from a true extravasation-related compartment syndrome
    • Chemotherapy
  • Envenomation
    • Snake Bite
  • Fetal Malpositioning: in neonatal cases
    • Intrauterine Malposition
    • Strangulation of Extremity by Umbilical Cord
  • Intensive Muscle Use
    • Seizures (see Seizures, [[Seizures]])
    • Tetany (see Tetanus, [[Tetanus]])
    • Vigorous Exercise
  • Intramuscular/Intra-Arterial/Intracompartmental Injection
  • Intraosseous Infusion (see Intraosseous Vascular Access, [[Intraosseous Vascular Access]])
  • Limb Hemorrhage: particularly from large vessel injury
  • Lithotomy Position: due to compromise of lower extremity perfusion
  • Malfunctioning Sequential Compression Device (SCD’s)
  • Massive Hypertonic Intravenous Fluid Infusion
  • Military Anti-Shock Trousers
  • Muscle Tear
    • Gastrocnemius Muscle
    • Peroneus Muscle
  • Myositis
  • Nephrotic Syndrome: due to decreased serum osmolarity
  • Open Reduction and Internal Fixation (Orthopedic): due to post-operative hematoma, muscle edema, or tight closure of deep fascia
    • Risk is minimized by releasing the tourniquet before wound closure to ensure that hemostasis is adequate
    • Risk is minimized by closing only the subcutaneous tissue and skin (not the fascia)
  • Pressurized Hypertonic Intravenous Contrast Infusion
  • Pressurized Pulsatile Irrigation System: intraoperative
  • Pressurized Fluid Infusion Into Joint During Arthroscopy: intraoperative
  • Rhabdomyolysis (see Rhabdomyolysis, [[Rhabdomyolysis]])
  • Routine Muscle Use
    • Horseback Riding
    • Stationary Bicycle Use
  • Ruptured Baker’s Cyst
  • Tight Splint/Cast/Dressing
  • Trauma
    • Fracture
      • Upper Extremity Fractures Associated with Compartment Syndrome
        • Supracondylar Fracture of Humerus: most common upper extremity fracture associated with compartment syndrome
        • Fracture of Radial or Ulnar Diaphysis: case reports of compartment syndrome
        • Fracture of the Surgical Neck of the Humerus: case reports of compartment syndrome
        • Colles Fracture: case reports of compartment syndrome
    • Gunshot Wound
    • Muscle Crush Injury
  • Vasculitis (see Vasculitis, [[Vasculitis]])

Physiology

  • Increased Compartment Pressure
    • Decreased Compartment Size
    • Increased Compartment Fluid Content

Clinical

  • Lower Extremity Pain (see Lower Extremity Pain, [[Lower Extremity Pain]])
    • Pain with passive flexion: common
  • Loss of Pulses: xxx
  • Peripheral Nerve Injury: prolonged elevated intracompartmental pressure may lead to irreversible peripheral nerve injury
  • Rhabdomolysis (see Rhabdomyolysis, [[Rhabdomyolysis]]):
  • xxx
  • xxx
  • xxx

Treatment

  • Management includes early fasciotomy and surgical decompression as neuromuscular dysfunction can develop as early as 6 hours after development of the compartment syndrome. Surgery performed within 6 to 12 hours can still result in approximately a 10% incidence of permanent deficit, whereas surgery performed after 12 hours is associated with permanent injury in 30% of patients. Amputation may be required. Permanent neuropathy, myonecrosis, fibrosis, and contractures are other long-term complications of compartment syndrome.

  • Intracompartment pressure >30 mm Hg: mandates fasciotomy


References

  • Acute compartment syndromes. Br J Surg 2002; 89:397-412
  • The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma 2002; 16:572-577
  • Vascular trauma and compartment syndromes. Surg Clin North Am 2002; 82:125-141
  • Acute compartment syndrome: diagnosis and immediate care. Hosp Med 2003; 64:296-298