COMPARTMENT SYNDROME

COMPARTMENT SYNDROME

• condition in which accumulating fluid and external compression – creates high pressure – within a closed osteofascial compartment – reducing perfusion of tissues with in that compartment – below a level necessary for viability
• compartments with non compliant fascial or osseous structures most commonly involved
  • anterior and deep posterior compartments of leg
  • volar compartment of forearm
• if pressure remains high for a long period : normal function of muscles, nerves affected – necrosis – permanent loss of functions – Volkmann's limb contracture occurs

Acute compartment syndrome

• severe form – following trauma – intra compartmental pressure elevated to high level for long period – enough to impede capillary permeability
• c/c exertional compartment syndrome : recurrence of increased pressure and exercise related

Pathophysiology

• decrease in compartment size or increase in compartment pressure
• capillary blood perfusion decrease
• tissue viability compromised
• local tissue necrosis – local tissue edema – further increase in pressure – vicious cycle

Etiology

• increase in compartment content volume
  • soft tissue injuries
  • osteotomies - #
  • bleeding disorders – burns – snake bite
  • c/c limb compression in drug addicts
  • post ischemic swelling following arterial occlusion
  • massive fluid resuscitation in critically injured
  • inadvertent use of hypertonic saline for regional anaesthesia
  • fluid pumps during arthroscopy
  • intra osseous fluid administration in children
• decrease in compartment size
  • extrinsic
    • tight cast / bandage
    • non compliant eschar in severe burns
    • inadvertent closure of fascia
  • intrinsic
    • stretching of the relaxed compartment as in IM nailing in non union leg #

Clinical features and diagnosis

• pain
• swollen, tense and tender
• altered sensation esp impaired two point discrimination and vibration sense
• peripheral pulses palpable (unless major arterial injury) – skin circulation will be satisfactory – problem lies in capillary circulation
• D/D
  • arterial injury : no pulse
  • peripheral nerve injury : no stretch pain
• monitoring of compartment pressure
  • Whiteside technique
  • Wick catheter
  • Slit catheter
  • Stryker hand held apparatus
• Fasciotomy if >30mm Hg (Mubarak)

Management

• impending compartment syndrome
  • release constrictive dressing
  • fluid replacement with crystalloid/colloid to maintain BP
  • blood transfusion
  • platelet and plasma replacement by maintenance of coagulability
  • limb kept at level of heart
    • produce maximum arteriovenous gradient
    • limb elevation : decrease arterial inflow without significant reduction in venous volume – further decrease perfusion
  • prophylactic fasciotomy : in high probability of developing compartment syndrome – if symptoms does not resolve with in 30-60 mts
• compartment syndrome
  • fasciotomy
    • indications
      • normotensive with positive clinical finding
      • >30 mm Hg compartment pressure
      • duration of increased pressure unknown or >8hrs
      • with low BP and compartment pressure >20mm Hg
• when in doubt compartment should be released
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