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Compartment syndrome

From Wikipedia, the free encyclopedia

Compartment syndrome
A forearm following emergency surgery for acute compartment syndrome
SpecialtyOrthopedics
SymptomsPain, numbness, pallor, decreased ability to move the affected limb[1]
ComplicationsAcute: Volkmann's contracture[2]
TypesAcute, chronic[1]
Causes
Diagnostic methodBased on symptoms, compartment pressure[5][1]
Differential diagnosisCellulitis, tendonitis, deep vein thrombosis, venous insufficiency[3]
Treatment

Compartment syndrome occurs when pressure in a body compartment rises.[6][7] This leads to a lack of blood supply to the tissue within it.[8] There are two types: acute and chronic.[6] Acute compartment syndrome can lead to a loss of the affected limb due to tissue death.[7][9]

Symptoms of acute compartment syndrome (ACS) include severe pain, decreased blood flow, decreased movement, numbness, and a pale limb.[5] It is most often due to physical trauma, like a bone fracture (up to 75% of cases) or a crush injury.[3][7] It can also occur after blood flow returns following a period of poor circulation.[4] Diagnosis is clinical, based on symptoms, not a specific test.[5] However, it may be supported by measuring the pressure inside the compartment.[5] It is classically described by pain out of proportion to the injury, or pain with passive stretching of the muscles.[10] Normal compartment pressure should be 12-18 mmHg; higher is abnormal and needs treatment.[9] Treatment is urgent surgery to open the compartment.[5] If not treated within six hours, it can cause permanent muscle or nerve damage.[5][11]

Chronic compartment syndrome (CCS), or chronic exertional compartment syndrome, causes pain with exercise.[1] The pain fades after activity stops.[12] Other symptoms may include numbness.[1] Symptoms usually resolve with rest.[1] Running and biking commonly trigger CCS.[1] This condition generally does not cause permanent damage.[1] Similar conditions include stress fractures and tendinitis.[1] Treatment may include physical therapy or, if that fails, surgery.[1]


ACS occurs in about 1-10% of those with a tibial shaft fracture [13] It is more common in males and those under 35, due to trauma.[3][14] German surgeon Richard von Volkmann first described compartment syndrome in 1881.[5] Delayed treatment can cause pain, nerve damage, cosmetic changes, and Volkmann's contracture.[2]

Signs and symptoms

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Compartment syndrome usually presents within a few hours of an inciting event, but it may present anytime up to 48 hours after.[7] The earliest symptom is a tense, "wood-like" feeling in the affected limb.[5][7] There may also be decreased pulses, paralysis, and pallor, along with paresthesia.[15] Usually, NSAIDs cannot relieve the pain.[16] High compartment pressure may limit the range of motion [17]. In acute compartment syndrome, the pain will not be relieved with rest.[6] In chronic exertional compartment syndrome the pain will dissipate with rest.[18]

Acute

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

There are five signs and symptoms of acute compartment syndrome.[7] They are known as the "5 Ps": pain, pallor, decreased pulse, paresthesia, and paralysis.[7] Pain and paresthesia are the early symptoms of compartment syndrome.[19][7]

Common symptoms are:

  • Pain: A person may feel pain greater than the exam findings.[7] This pain may not be relieved by strong painkillers, including opioids like morphine.[20] It may be due to nerve damage from ischemia [7]. A person may experience pain disproportionate to the findings of the physical examination.[21] The pain is aggravated by passively stretching the muscle group within the compartment.[21] However, such pain may disappear in the late stages of the compartment syndrome.[19]
  • Paresthesia (altered sensation): A person may complain of "pins and needles," numbness, and a tingling sensation. This may progress to loss of sensation (anesthesia) if no intervention is made.[19]

Uncommon symptoms are:

  • Paralysis: Paralysis of the limb is a rare, late finding.[5] It may indicate both a nerve or muscular lesion.[19]
  • Pallor: Pallor describes the loss of color to the affected limb.[6] Other skin changes can include swelling, stiffness, or cold temperature.[9]
  • Pulselessness: A lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often lower than arterial pressures.[5] Absent pulses occur only with arterial injury or late-stage compartment syndrome, when pressures are very high.[5]

Chronic

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Chronic exertional compartment syndrome, CECS, may cause pain, tightness, cramps, weakness, and numbness.[22] This pain can last for months or even years, but rest may relieve it.[23] There may also be mild weakness in the affected area.[12]

Exercise causes these symptoms.[24] They start with muscle tightness, then a painful burning if exercise continues.[24] After exercise stops, the compartment pressure will drop in a few minutes.[18] This will relieve the pain.[23] Symptoms will occur after a certain level of exercise.[12] This threshold can range anywhere from 30 seconds of running to 2–3 miles of running.[25] CECS most often occurs in the lower leg.[12] The anterior compartment is most affected.[12] Foot drop is a common symptom.[23][24]

===Complications=== Failure to relieve the pressure can result in the death of tissues (necrosis) in the affected anatomical compartment, since the ability of blood to enter the smallest vessels in the compartment (capillary perfusion pressure) will fall. This, in turn, leads to progressively increasing oxygen deprivation of the tissues dependent on this blood supply. Without sufficient oxygen, the tissue will die.[26] On a large scale, this can cause Volkmann's contracture in affected limbs, a permanent and irreversible process.[27][28][29] Other reported complications include neurological deficits of the affected limb, gangrene, and chronic regional pain syndrome.[30] Rhabdomyolysis and subsequent kidney failure are also possible complications. In some case series, rhabdomyolysis is reported in 23% of patients with ACS.[19]

Causes

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Acute

[edit]

Acute compartment syndrome (ACS) is a medical emergency that can develop after traumatic injuries, such as in automobile accidents or dynamic sporting activities – for example, a severe crush injury or an open or closed fracture of an extremity. Rarely, ACS can develop after a relatively minor injury, or due to another medical issue.[31] The lower legs and the forearms are the most frequent sites affected by compartment syndrome. Other areas of the body such as thigh, buttock, hand, abdomen, and foot can also be affected.[19][14] The most common cause of acute compartment syndrome is fracture of a bone, most commonly the tibia.[32] There is no difference between acute compartment syndrome originating from an open or closed fracture.[16] Leg compartment syndrome is found in 2% to 9% of tibial fractures. It is strongly related to fractures involving the tibial diaphysis as well as other sections of the tibia.[33] Direct injury to blood vessels can lead to compartment syndrome by reducing the downstream blood supply to soft tissues. This 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.[19] 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. Intravenous drug injection, casts, prolonged limb compression, crush injuries, anabolic steroid use, vigorous exercise, and eschar from burns can also cause compartment syndrome.[34][35] Patients on anticoagulant therapy have an increased risk of bleeding into a closed compartment.[19]

Abdominal compartment syndrome occurs when the intra-abdominal pressure exceeds 20 mmHg and abdominal perfusion pressure is less than 60 mmHg. This disease process is associated with organ dysfunction and multiple organ failures. There are many causes, which can be broadly grouped into three mechanisms: primary (internal bleeding and swelling); secondary (vigorous fluid replacement as an unintended complication of resuscitative medical treatment, leading to the acute formation of ascites and a rise in intra-abdominal pressure); and recurrent (compartment syndrome that has returned after the initial treatment of secondary compartment syndrome).[36]

Compartment syndrome after snake bite is rare.[37] Its incidence varies from 0.2 to 1.36% as recorded in case reports.[38] Compartment syndrome is more common in children possibly due to inadequate volume of the bodily fluid to dilute the snake venom.[37] Increased white blood cell count of more than 1,650/μL and aspartate transaminase (AST) level of more than 33.5 U/L could increase the risk of developing compartment syndrome. Otherwise, those bitten by venomous snakes should be observed for 48 hours to exclude the possibility of compartment syndrome.[38]

Acute compartment syndrome due to severe/uncontrolled hypothyroidism is rare.[39]

Chronic

[edit]

When compartment syndrome is caused by repetitive use of the muscles, it is known as chronic compartment syndrome (CCS).[40][41] This is usually not an emergency, but the loss of circulation can cause temporary or permanent damage to nearby nerves and muscles.

A subset of chronic compartment syndrome is chronic exertional compartment syndrome (CECS), often called exercise-induced compartment syndrome (EICS).[42] Oftentimes, CECS is a diagnosis of exclusion.[43] CECS of the leg is a condition caused by exercise which results in increased tissue pressure within an anatomical compartment due to an acute increase in muscle volume – as much as 20% is possible during exercise.[44] When this happens, pressure builds up in the tissues and muscles causing tissue ischemia.[44] An increase in muscle weight will reduce the compartment volume of the surrounding fascial borders and result in an increased compartment pressure.[42] An increase in the pressure of the tissue can force fluid to leak into the interstitial space (extracellular fluid), leading to a disruption of the micro-circulation of the leg.[42] This condition occurs commonly in the lower leg and various other locations within the body, such as the foot or forearm. CECS can be seen in athletes who train rigorously in activities that involve constant repetitive actions or motions.[42]

Pathophysiology

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In a normal human body, blood flow from the arterial system (higher pressure) to venous system (lower pressure) requires a pressure gradient. When this pressure gradient is diminished, blood flow from the artery to the vein is reduced. This causes a backup of blood and excessive fluid to leak from the capillary wall into spaces between the soft tissue's cells, causing swelling of the extracellular space and a rise in intracompartmental pressure. This swelling of the soft tissues surrounding the blood vessels compresses the blood and lymphatic vessels further, causing more fluid to enter the extracellular spaces, leading to additional compression. The pressure continues to increase due to the non-compliant nature of the fascia containing the compartment.[7] This worsening cycle can eventually lead to a lack of sufficient oxygen in the soft tissues (tissue ischemia) and tissue death (necrosis). Tingling and abnormal sensation (paresthesia) can begin as early as 30 minutes from the start of tissue ischemia and permanent damage can occur as early as 12 hours from the onset of the inciting injury.[19]

Diagnosis

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Compartment syndrome is a clinical diagnosis, meaning that a medical provider's examination and the patient's history usually give the diagnosis.[14] Apart from the typical signs and symptoms, measurement of intracompartmental pressure can also be important for diagnosis.[45][14] Using a combination of clinical diagnosis and serial intracompartmental pressure measurements increases both the sensitivity and specificity of diagnosing compartment syndrome.[9] A transducer connected to a catheter is inserted 5 cm into the zone of injury.[5]

A compartment pressure no less than 30 mmHg of the diastolic pressure in a conscious or unconscious person is associated with compartment syndrome.[46] Fasciotomy is indicated in that case. For those patients with low blood pressure (hypotension), a pressure of 20 mmHg higher than the intracompartmental pressure is associated with compartmental syndrome.[19] Noninvasive methods of diagnosis such as near-infraredspectroscopy (NIRS) which uses sensors on the skin, shows promise in controlled settings. However, with limited data in uncontrolled settings, clinical presentation and intracompartmental pressure remain the gold standard for diagnosis.[47]

Chronic exertional compartment syndrome is usually a diagnosis of exclusion, with the hallmark finding being absence of symptoms at rest. Measurement of intracompartmental pressures during symptom reproduction (usually immediately following running) is the most useful test. Imaging studies (X-ray, CT, MRI) can be useful in ruling out other more common diagnoses instead of confirming the diagnosis of compartment syndrome.[12] Additionally, MRI has been shown to be effective in diagnosing chronic exertional compartment syndrome.[48] The average duration of symptoms prior to diagnosis is 28 months.[49]

Treatment

[edit]

Acute

[edit]
Use of a skin graft to close a fasciotomy wound.

Any external compression (tourniquet, orthopedic casts or dressings applied on the affected limb) should be removed. Cutting of the cast will reduce the intracompartmental pressure by 65%, followed by 10 to 20% pressure reduction once padding is cut. After removal of the external compression the limb should be placed at the level of the heart. 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. This surgical procedure is performed inside an operating theater under general or local anesthesia.[19] The timing of the fasciotomy wound closure is debated. Some surgeons suggest wound closure should be done seven days after fasciotomy.[19] Multiple techniques exist for closure of the surgical site including vacuum-assisted and shoelace. Both techniques are acceptable methods for closure, but the vacuum-assisted technique has led to longer hospitalization time.[50] A skin graft may be required to close the wound, which would complicate the treatment with a much longer hospitalization stay.[50]

Fasciotomy is overused and non-therapeutic in many cases of compartment syndrome due to snake bites due to Crotalid (rattlesnake) and related snakes such as lance-head, and may actually worsen prognosis.[51][52][53] Compartment syndrome due to snake bite should be treated with antivenom, and, unlike more common causes, fasciotomy is rarely indicated.[54] If the pressure does not reduce after administration of antivenom, the treatment is to administer more antivenom. Compartment pressure should be measured before and after administration of antivenom, and only those patients who fail to respond to additional antivenom should receive a fasciotomy.[55][56][57][58]

Chronic

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Treatment for chronic exertional compartment syndrome can include decreasing or subsiding exercise and/or exacerbating activities, massage, non-steroidal anti-inflammatory medication, and physiotherapy. Chronic compartment syndrome in the lower leg can be treated conservatively or surgically. Conservative treatment includes rest, anti-inflammatory medications, and manual decompression. Warming the affected area with a heating pad may help to loosen the fascia prior to exercise. Icing the area may result in further constriction of the fascia and is not recommended before or after exercise. The use of devices that apply external pressure to the area, such as splints, casts, and tight wound dressings, should be avoided.[59] If symptoms persist after conservative treatment or if an individual does not wish to give up the physical activities which bring on symptoms, compartment syndrome can be treated by a surgery known as a fasciotomy.

A US military study conducted in 2012 found that teaching individuals with lower leg chronic exertional compartment syndrome to change their running style to a forefoot running technique abated symptoms in those with symptoms limited to the anterior compartment.[60] Running with a forefoot strike limits use of the tibialis anterior muscle which may explain the relief in symptoms in those with anterior compartment syndrome.

Hyperbaric oxygen therapy has been suggested by case reports – though as of 2011 not proven in randomized control 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.[61][62]

Prognosis

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A mortality rate of 47% has been reported for acute compartment syndrome of the thigh. According to one study the rate of fasciotomy for acute compartment syndrome varied from 2% to 24%.[19] This is due to uncertainty and differences in labeling a condition as acute compartment syndrome. The most significant prognostic factor in people with acute compartment syndrome is time to diagnosis and subsequent fasciotomy.[31] In people with a missed or late diagnosis of acute compartment syndrome, limb amputation may be necessary for survival.[63][45] Following a fasciotomy, some symptoms may be permanent depending on factors such as which compartment, time until fasciotomy, and muscle necrosis. Muscle necrosis can occur quickly, within 3 hours of original injury in some studies.[45] Fasciotomy of the lateral compartment of the leg may lead to symptoms due to the nerves and muscles in that compartment. These may include foot drop, numbness along leg, numbness of big toe, pain, and loss of foot eversion.[11]

Epidemiology

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In one case series of 164 people with acute compartment syndrome, 69% of the cases had an associated fracture. The authors of that article also calculated an annual incidence of acute compartment syndrome of 1 to 7.3 per 100,000.[64] There are significant differences in the incidence of acute compartment syndrome based on age and gender in the setting of trauma.[14] Men are ten times more likely than women to develop ACS. The mean age for ACS in men is 30 years while the mean age is 44 years for women.[19] Acute compartment syndrome may occur more often in individuals less than 35 years old due to increased muscle mass within the compartments .[7] The anterior compartment of the leg is the most common site for ACS.[7][65]

See also

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References

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