Trauma
A 27 year old man presents to the Emergency Department complaining of pain in his left lower leg. He was seen in the Emergency Department 2 days ago following a football injury to the same leg. An x-ray of the tibia and fibula was performed on this first presentation and no fracture was seen. He was discharged with crutches as he was unable to weight bear, he was not immobilised. On examination today the left lower leg is swollen and tender. There is severe pain on passive flexion and extension of the toes. You cannot feel a dorsalis pedis pulse. You review the x-ray from 2 days ago and can see a tibial shaft fracture. What is the recommended treatment for this patient's condition?
Answer:
- The patient has signs and features of compartment syndrome. This is treated with fasciotomy.
- Fasciotomy
- Casts or occlusive dressings should be split completely, and padding or circumferential dressings should be released.
- If symptoms are not relieved with removal of occlusive dressings, complete fasciotomy of all compartments with elevated pressures is indicated.
- Fasciotomy performed within a 6-hour window from the initiation of compartment syndrome leads to lower compartment syndrome-related amputation and death rates, compared with delays >6 hours.
- The length of skin incision affects fascial decompression in the extremity with an acute compartment syndrome. Long incisions do not cause significant additional morbidity and do not further influence the complication rate or the functional result. They decrease the risk of excess skin acting as a compartment envelope.
Compartment Syndrome of Extremities
Trauma
Last Updated: 18th April 2023
Compartment syndrome develops when the pressure within a closed osteofascial compartment exceeds that of the perfusion pressure of the tissues, compromising the circulation and function of the tissues therein, resulting in tissue ischaemia, necrosis and nerve damage. This increased pressure may be caused by an increase in compartment content (e.g. bleeding into the compartment or swelling after revascularisation of an ischaemic extremity) or a decrease in the compartment size (e.g. a constrictive dressing).
Causes
Compartment syndrome can occur wherever muscle is contained within a closed fascial space. Common areas for compartment syndrome include the lower leg, forearm, foot, hand, gluteal region, and thigh.
Any injury to an extremity can cause compartment syndrome. However, certain injuries or activities are considered high risk, including:
- Tibia and forearm fractures
- Injuries immobilised in tight dressings or casts
- Severe crush injury to muscle
- Localised, prolonged external pressure to an extremity e.g. restrictive plaster, dressing or splint
- Increased capillary permeability secondary to reperfusion of ischaemic muscle
- Burns
- Excessive exercise
Clinical features
To recognise extremity compartment syndrome in a timely fashion, it is important to maintain a high index of suspicion and serially examine patients at risk to document changes over time.
- Symptoms
- Pain greater than expected and out of proportion to the stimulus or injury
- Signs
- Pain on passive muscle stretch (earliest sign)
- Tense swelling of the affected compartment (early sign)
- Paresthesia or altered sensation distal to the affected compartment (early sign)
- Pallor caused by vascular compromise (uncommon or late sign)
- Absence of a palpable distal pulse (uncommon or late sign)
- Weakness or paralysis of involved muscle (late sign and may imply significant muscle necrosis and indicate need for amputation)
Differential diagnosis
- Deep vein thrombosis
- Stress fracture
- Acute limb ischaemia
- Chronic venous insufficiency
- Muscle tear
- Haematoma
- Extremity fracture
- Tigh casts, dressings, external wrappings
Investigations
- Diagnosis is clinical based on the history of injury and physical signs, coupled with a high index of suspicion.
- Compartment pressure measurement
- Several pressure measurement devices are available for determining intracompartmental pressures.
- Pressure should be measured in all compartments and at multiple sites, particularly within 5 cm of the level of injury, and the highest measurement obtained should dictate management decisions.
- The differential pressure (i.e. the difference between diastolic BP and measured compartment pressure: diastolic BP minus compartment pressure) is measured.
- Significant muscle damage can occur with compartment pressures >30 to 40 mmHg or within 10 to 30 mmHg of diastolic BP.
- Serum creatine kinase
- Reflects muscle cell lysis and muscle necrosis
- Urine myoglobin
- Reflects muscle cell lysis and muscle necrosis
Management
- Fasciotomy
- Casts or occlusive dressings should be split completely, and padding or circumferential dressings should be released.
- If symptoms are not relieved with removal of occlusive dressings, complete fasciotomy of all compartments with elevated pressures is indicated.
- Fasciotomy performed within a 6-hour window from the initiation of compartment syndrome leads to lower compartment syndrome-related amputation and death rates, compared with delays >6 hours.
- The length of skin incision affects fascial decompression in the extremity with an acute compartment syndrome. Long incisions do not cause significant additional morbidity and do not further influence the complication rate or the functional result. They decrease the risk of excess skin acting as a compartment envelope.
- Muscle viability can also be checked intraoperatively.
- If there is clinical evidence of compartment syndrome with a probable duration >8 hours, with evidence of muscle necrosis, primary amputation rather than fasciotomy should be considered, following multidisciplinary discussion.
- Supportive measures include analgesia and fluids.
- Patient-controlled analgesia, with either morphine or another opioid analgesic medication, is usually effective.
- Patients should also receive adequate amounts of fluids to achieve a urine output of >0.5 mL/kg. Furthermore, intravenous mannitol (given only after adequate hydration has been established by clinical measures) can be used to enhance diuresis.
- In cases of rhabdomyolysis, patients should also receive sodium bicarbonate for urinary alkalinisation, although the importance of urinary alkalinisation is under question. Target urinary pH is 6.5.
- Patients with anuria unresponsive to hydration may require haemodialysis. Haemodialysis corrects metabolic acidosis and electrolyte abnormalities, and removes plasma myonecrotic toxins.
- Post-fasciotomy, the following measures should be considered:
- Wound care, important due to the secondary risk of infection and to identify in a timely fashion the presence of necrotic tissue that needs to be debrided.
- Covering fasciotomy wounds with skin grafts, after the condition of the patient has been optimised.
- Rest, analgesia, and physical and occupational therapy (with range of motion exercises).
Complications
- Permanent sensory or motor neurological deficit
- Ischaemic contracture
- Wound infection
- Rhabdomyolysis and acute renal failure
- Limb loss
- Phantom pain post-amputation
- Psychological effects post-amputation
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
