Compartment syndrome

Template:Short description Template:Cs1 config Template:Infobox medical condition (new) Compartment syndrome is a serious medical condition in which increased pressure within a body compartment compromises blood flow and tissue function, potentially leading to permanent damage if not promptly treated.<ref name="Don2014" /><ref name="Stat2020">Template:Cite journal</ref><ref name="Pei2008">Template:Cite book</ref> There are two types: acute and chronic.<ref name="PMH2017">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Acute compartment syndrome can lead to a loss of the affected limb due to tissue death.<ref name="Stat2020" /><ref name="McQ2014" />

Symptoms of acute compartment syndrome (ACS) include severe pain, decreased blood flow, decreased movement, numbness, and a pale limb.<ref name=Don2014>Template:Cite journal</ref> It is most often due to physical trauma, like a bone fracture (up to 75% of cases) or a crush injury.<ref name=Fer2018/><ref name=Stat2020 /> It can also occur after blood flow returns following a period of poor circulation.<ref name=Sch2016>Template:Cite journal</ref> Diagnosis is clinical, based on symptoms, not a specific test.<ref name=Don2014/> However, it may be supported by measuring the pressure inside the compartment.<ref name="Don2014" /> It is classically described by pain out of proportion to the injury, or pain with passive stretching of the muscles.<ref name="Don2014" /> Normal compartment pressure should be 12-18 mmHg; higher is abnormal and needs treatment.<ref name=McQ2014>Template:Cite journal</ref> Treatment is urgent surgery to open the compartment.<ref name=Don2014/> If not treated within six hours, it can cause permanent muscle or nerve damage.<ref name=Don2014/><ref name="Jen2017">Template:Cite journal</ref>

Chronic compartment syndrome (CCS), or chronic exertional compartment syndrome, causes pain with exercise.<ref name="Orth2009">Template:Cite journal</ref> The pain fades after activity stops.<ref name="Blackman_2000">Template:Cite journal</ref> Other symptoms may include numbness.<ref name=Orth2009/> Symptoms usually resolve with rest.<ref name=Orth2009/> Running and biking commonly trigger CCS.<ref name=Orth2009/> This condition generally does not cause permanent damage.<ref name=Orth2009/> Similar conditions include stress fractures and tendinitis.<ref name="Orth2009" /> Treatment may include physical therapy or, if that fails, surgery.<ref name=Orth2009/>

ACS occurs in about 1-10% of those with a tibial shaft fracture.<ref name="Stat2020" /> It is more common in males and those under 35, due to trauma.<ref name="Fer2018">Template:Cite book</ref><ref name="Gar2014">Template:Cite journal</ref> German surgeon Richard von Volkmann first described compartment syndrome in 1881.<ref name="Don2014" /> Delayed treatment can cause pain, nerve damage, cosmetic changes, and Volkmann's contracture.<ref name="El2013">Template:Cite book</ref>

Signs and symptoms

Compartment syndrome usually presents within a few hours of an inciting event, but it may present anytime up to 48 hours after.<ref name=Stat2020 /> The earliest symptom is a tense, "wood-like" feeling in the affected limb.<ref name="Don2014" /><ref name=Stat2020 /> There may also be decreased pulses, paralysis, and pallor, along with paresthesia.<ref>Template:Cite journal</ref> Usually, NSAIDs cannot relieve the pain.<ref name="Via_2015">Template:Cite journal</ref> High compartment pressure may limit the range of motion<ref>Template:Cite journal</ref> In acute compartment syndrome, the pain will not be relieved with rest.<ref name="PMH2017" /> In chronic exertional compartment syndrome the pain will dissipate with rest.<ref name="StatPearls_2020">Template:Cite journal</ref>

Acute

File:Acute Compartment Syndrome with blister formation.JPG

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

There are five signs and symptoms of acute compartment syndrome.<ref name="Stat2020" /> They are known as the "5 Ps": pain, pallor, decreased pulse, paresthesia, and paralysis.<ref name="Stat2020" /> Pain and paresthesia are the early symptoms of compartment syndrome.<ref name="Alessio 2015">Template:Cite journal</ref><ref name=Stat2020 />

Common symptoms are:

• Pain: A person may feel pain greater than the exam findings.<ref name=Stat2020 /> This pain may not be relieved by strong painkillers, including opioids like morphine.<ref>Template:Cite journal</ref> It may be due to nerve damage from ischemia.<ref name="Stat2020" /> A person may experience pain disproportionate to the findings of the physical examination.<ref name="Lorange_2023">Template:Cite journal</ref> The pain is aggravated by passively stretching the muscle group within the compartment.<ref name="Lorange_2023" /> However, such pain may disappear in the late stages of the compartment syndrome.<ref name="Alessio 2015" />
• 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.<ref name="Alessio 2015" />

Uncommon symptoms are:

• Paralysis: Paralysis of the limb is a rare, late finding.<ref name="Don2014" /> It may indicate both a nerve or muscular lesion.<ref name="Alessio 2015" />
• Pallor: Pallor describes the loss of color to the affected limb.<ref name="PMH2017" /> Other skin changes can include swelling, stiffness, or cold temperature.<ref name="McQ2014" />
• Pulselessness: A lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often lower than arterial pressures.<ref name="Don2014" /> Absent pulses occur only with arterial injury or late-stage compartment syndrome, when pressures are very high.<ref name="Don2014" />

Chronic

Chronic exertional compartment syndrome, CECS, may cause pain, tightness, cramps, weakness, and numbness.<ref name="Dunn">Template:Cite journal</ref> This pain can last for months or even years, but rest may relieve it.<ref name="Bong" /> There may also be mild weakness in the affected area.<ref name="Blackman_2000" />

Exercise causes these symptoms.<ref name="Awbrey" /> They start with muscle tightness, then a painful burning if exercise continues.<ref name="Awbrey" /> After exercise stops, the compartment pressure will drop in a few minutes.<ref name="StatPearls_2020" /> This will relieve the pain.<ref name="Bong" /> Symptoms will occur after a certain level of exercise.<ref name="Blackman_2000" /> This threshold can range anywhere from 30 seconds of running to 2–3 miles of running.<ref>Template:Cite journal</ref> CECS most often occurs in the lower leg.<ref name="Blackman_2000" /> The anterior compartment is most affected.<ref name="Blackman_2000" /> Foot drop is a common symptom.<ref name="Bong">Template:Cite journal</ref><ref name="Awbrey">Template:Cite journal</ref>

Causes

Acute

Acute compartment syndrome (ACS) is a medical emergency.<ref name="Don2014" /> It can develop after traumatic injuries, like car accidents, gunshot wounds, fractures, or intense sports.<ref name="Mortensen_2021b">Template:Cite journal</ref> Examples include a severe crush injury or an open or closed fracture of an extremity.<ref name="Mortensen_2021b" /> Rarely, ACS can develop after a minor injury or another medical issue.<ref name="Taylor_2012">Template:Cite journal</ref> It can also affect the thigh, buttock, hand, abdomen, and foot.<ref name="Alessio 2015" /><ref name=Gar2014 /> The most common cause of acute compartment syndrome is a fractured bone, usually the tibia.<ref name="Gar2014"/><ref>Template:Cite journal</ref> Leg compartment syndrome occurs in 1% to 10% of tibial fractures.<ref name="Stat2020" /> It is strongly linked to tibial diaphysis fractures and other tibial injuries.<ref>Template:Cite journal</ref> Direct injury to blood vessels can reduce blood flow to soft tissues, causing compartment syndrome.<ref name="Mortensen_2021b"/> Compartment syndrome can also be caused by:

• intravenous drug injection
• casts
• prolonged limb compression
• crush injuries
• anabolic steroid use
• vigorous exercise
• eschar from burns<ref name="Konstantakos_2007">Template:Cite journal</ref><ref name="Salcido_2007">Template:Cite journal</ref>

Patients on anticoagulant therapy, or those with blood disorders such as hemophilia or leukemia are at higher risk of developing compartment syndrome.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="Alessio 2015" />

Abdominal compartment syndrome occurs when the intra-abdominal pressure exceeds 20 mmHg and abdominal perfusion pressure is less than 60 mmHg.<ref name="Maerz_2008" /> 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).<ref name="Maerz_2008">Template:Cite journal</ref><ref>Template:Cite journal</ref>

Compartment syndrome after snake bite is rare.<ref name="pmid30834067">Template:Cite journal</ref> Its incidence varies from 0.2 to 1.36% as recorded in case reports.<ref name="pmid26561300">Template:Cite journal</ref> Compartment syndrome after a snake bite is more common in children.<ref name="pmid30834067" /> Increased white blood cell count of more than 1,650/μL and aspartate transaminase (AST) level of more than 33.5 U/L are associated with developing compartment syndrome.<ref name="pmid26561300" /> Otherwise, those bitten by venomous snakes should be observed for 48 hours to exclude the possibility of compartment syndrome.<ref name="pmid26561300" />

Acute compartment syndrome due to severe/uncontrolled hypothyroidism is rare.<ref>Template:Cite journal</ref>

Chronic

When repeated use of the muscles causes compartment syndrome, it is chronic compartment syndrome (CCS).<ref name="Wanich_2007">Template:Cite journal</ref><ref name="Verleisdonk_2003">Template:Cite journal</ref> This is usually not an emergency, but loss of circulation can damage nearby nerves and muscles.<ref name="Verleisdonk_2003" /> The damage may be temporary or permanent.<ref name="Wanich_2007" /><ref name="Verleisdonk_2003" />

A subset of chronic compartment syndrome is chronic exertional compartment syndrome (CECS), often called exercise-induced compartment syndrome (EICS).<ref name="Cetinus_2004">Template:Cite journal</ref> CECS is often a diagnosis of exclusion.<ref name="Liu_2017">Template:Cite journal</ref> CECS of the leg is caused by exercise.<ref name= "Touliopolous _1999">Template:Cite journal</ref> This condition occurs commonly in the lower leg and various other locations within the body, such as the foot or forearm.<ref name="Blackman_2000" /> CECS can be seen in athletes who train rigorously in activities that involve constant repetitive actions or motions.<ref name="Cetinus_2004"/>

Pathophysiology

ACS is defined as a critical pressure increase within a confined compartmental space causing a decline in the perfusion pressure to the tissue within that compartment .<ref name="Don2014" /> A normal human body needs a pressure gradient for blood flow.<ref name="Stella_2019">Template:Cite journal</ref> It must go from the higher-pressure arterial system to the lower-pressure venous system.<ref name="Don2014" /><ref name="Stella_2019" /> This causes blood to back up.<ref name="Don2014" /> Excess fluid leaks from the capillaries into the spaces between the soft tissue's cells.<ref>Template:Citation</ref> This swells the extracellular space and raises the pressure in the compartment.<ref name="Don2014" /><ref name="Donaldson_2014">Template:Cite journal</ref> The swelling of the soft tissues around the blood vessels compresses the blood and lymphatic vessels.<ref name="Donaldson_2014" /><ref name="Stella_2019" /> This causes more fluid to enter the extracellular spaces, leading to further compression.<ref name="Don2014" /> The pressure keeps rising due to the non-compliant fascia in the compartment.<ref name="Don2014" /> This cycle can cause tissue ischemia, a lack of oxygen, and necrosis, or tissue death.<ref name="Stat2020" /><ref name="Don2014" /><ref name="Stella_2019" /> Paresthesia, or tingling, can start as early as 30 minutes after tissue ischemia begins.<ref name="Semenza_2000">Template:Cite journal</ref> Permanent damage can occur 12 hours after the injury starts.<ref name="Semenza_2000" />

File:Compartment Syndrome in Muscle (cleaned up) (annotated).jpg

Pathophysiology of Compartment Syndrome

The reduced blood supply can trigger inflammation.<ref name="Stat2020" /> This can cause the soft tissues to swell.<ref name="Don2014" /> Reperfusion therapy can worsen this inflammation.<ref name="Don2014" /> The fascia that defines the limbs' compartments does not stretch.<ref name="Stat2020" /> Even a small bleed or muscle swelling can greatly raise the pressure.<ref name="PMH2017" /><ref name="Stat2020" /><ref name="Don2014" />

The pathophysiology of CECS is not entirely understood. In CECS, pressure in an anatomical compartment increases due to a 20% increase in muscle volume.<ref name="Touliopolous _1999" /> This builds pressure in the tissues and muscles, causing ischemia.<ref name="Touliopolous _1999" /> Increased muscle weight reduces the compartment volume of the surrounding fascial borders, raising compartment pressure.<ref name="Cetinus_2004" /> 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.<ref name="Cetinus_2004" />

Diagnosis

File:Compartment syndrome - updated.jpg

Pressure gauge used to measure intracompartmental pressure in suspected compartment syndrome. The device consists of a needle catheter that is inserted directly into the affected limb which is then connected to a pressure transducer. The transducer can relay the measurement to an A-line monitor or a standard pressure gauge.

Compartment syndrome is a clinical diagnosis.<ref name="Gar2014" /> It comes from a provider's exam and the patient's history.<ref name="Don2014" /><ref name="Gar2014" /> Diagnosis may also require measuring intracompartmental pressure.<ref name="Don2014" /><ref name="Stat2020" /> Using both methods increases the accuracy of diagnosing compartment syndrome.<ref name="Pei2008" /> A transducer connected to a catheter is inserted 5 cm into the zone of injury to measure the intracompartmental pressure.<ref name="McQ2014" /><ref name="Don2014" /> Normal pressure is 10 mmHg.<ref name="Don2014" /> Anything greater can compromise circulation, and 30 mmHg has been commonly cited as the upper threshold before circulation is lost.<ref name="Don2014" />

Noninvasive methods, like near-infrared spectroscopy (NIRS), show promise in controlled settings.<ref name="Walters_2019">Template:Cite journal</ref> NIRS uses sensors on the skin.<ref name="Walters_2019" /> However, with limited data, the gold standard for diagnosis is the clinical presentation and intracompartmental pressure.<ref name="Walters_2019" />

Chronic exertional compartment syndrome is often diagnosed by ruling out other conditions.<ref name="Blackman_2000" /><ref name="Awbrey" /> The key sign is that there are no symptoms when at rest.<ref name="Orth2009" /><ref name="Davis_2013">Template:Cite journal</ref> The best test is to measure intracompartmental pressures after running, when symptoms return.<ref name="Davis_2013" /><ref name="Orth2009" /> Tests like X-rays, CT scans, and MRIs help rule out other problems.<ref name="Blackman_2000" /> But they don't confirm compartment syndrome/<ref name="Blackman_2000" /> However, MRI is effective for diagnosing chronic exertional compartment syndrome.<ref>Template:Citation</ref>

Treatment

Acute

File:Fasciotomy (Post Skin-Graft).jpg

A skin graft is used to close a fasciotomy wound.

If external compression, such as a cast or tourniquet, has caused increased pressure, it is removed and the limb placed at heart level. Otherwise, fasciotomy, a cut into the fascia beneath the skin, immediately decreases pressure and is generally the only effective treatment.<ref name="Alessio 2015" /> Although closing a fasciotomy wound quickly reduces complications, this is not typically achievable as compartment syndrome may recur. Before the wound is closed, it may be covered with moist dressings or, in some cases, treated with negative-pressure wound therapy, which can additionally be used for closure. Closure is often achieved using the so-called shoelace technique, where staples are inserted into the skin which are used to pull the sides of the wound together with a thread. A skin graft may be needed to close the wound.<ref name = "Igoumenou_2019">Template:Citation</ref> Fasciotomy is often not necessary when compartment syndrome is caused by snake bites, where pressure may instead be relieved with antivenom.<ref name="Türkmen_2016">Template:Cite journal</ref>

Chronic

Chronic exertional compartment syndrome can be treated by reducing or stopping exercise and other activities; massage; non-steroidal anti-inflammatory medication; and physiotherapy<ref name="Orth2009" /> If symptoms persist after basic treatment, compartment syndrome may be treated with a fasciotomy.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="Davis_2013" />

Prognosis

Researchers have reported a mortality rate of 47% for acute compartment syndrome of the thigh.<ref>Template:Cite journal</ref> A study showed the fasciotomy rate for acute compartment syndrome ranges from 2% to 24%.<ref name="Alessio 2015" /> The key factor in acute compartment syndrome is the time to diagnosis and fasciotomy.<ref name="Taylor_2012" /> A missed or late diagnosis may require limb amputation to survive.<ref>Template:Cite journal</ref><ref name="Long_2019">Template:Cite journal</ref> After a fasciotomy, some symptoms may be permanent.<ref name="Long_2019" /> It depends on which compartment was affected, the time until surgery, and muscle necrosis.<ref name="Taylor_2012" /><ref name="Mortensen_2021b"/> Muscle necrosis can happen fast, sometimes within just 3 hours after an injury.<ref name="Long_2019" /> A fasciotomy in the leg's lateral compartment might cause symptoms affecting nearby nerves and muscles.<ref name="Jen2017" /> These may include foot drop, numbness along leg, numbness of big toe, pain, and loss of foot eversion.<ref name="Jen2017" />

Complications

If pressure is not relieved, tissues may die (necrosis) in the affected compartment.<ref name="McQ2014" /><ref name="Taylor_2012" /> Blood will be unable to enter the smallest vessels.<ref name="Don2014" /><ref name="Donaldson_2014" /> Capillary perfusion pressure will fall.<ref name="Don2014" /><ref name="Donaldson_2014" /> This, in turn, leads to a gradual lack of oxygen in the tissues that depend on this blood supply.<ref>Template:Cite journal</ref> Without enough oxygen, the tissue will die.<ref name="Long_2019" /> On a large scale, this can cause Volkmann's contracture in the affected limbs.<ref name="Elsevier_2017">Template:Cite book</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> It is permanent and irreversible.<ref name="Elsevier_2017" /> Other complications include neurological deficits, gangrene, and chronic regional pain syndrome.<ref>Template:Cite journal</ref> Rhabdomyolysis and kidney failure are also possible.<ref>Template:Cite journal</ref> Some case series report rhabdomyolysis in 23% of patients with ACS.<ref name="Alessio 2015" />

Epidemiology

In a case series of 164 people with acute compartment syndrome, 69% had an associated fracture.<ref name="McQueen_2000">Template:Cite journal</ref> The article's authors found that the yearly rate of acute compartment syndrome is 1 to 7.3 cases per 100,000 people.<ref name="McQueen_2000" /> It varies greatly by age and gender in trauma.<ref name="Gar2014" /> Men are ten times more likely than women to get ACS.<ref name="Stat2020" /> The mean age for ACS is 30 in men and 44 in women.<ref name="Alessio 2015" /> People under 35 may get ACS more often.<ref name="Stat2020" /><ref name="Don2014" /> This is likely because they have more muscle mass.<ref name="Don2014" /><ref name="Stat2020" /> The anterior compartment of the leg is where ACS usually happens.<ref name="Stat2020" /><ref>Template:Cite journal</ref>

In children

The pathophysiology of acute compartment syndrome in children is the same as adults.<ref name=":0">Template:Citation</ref> However, cases are complicated by challenges in examination and communication with pediatric patients.<ref name=":0" /> Children may not be able to effectively report their pain symptoms.<ref name=":1">Template:Cite journal</ref> In addition, it can take longer to develop high pressures in pediatric compartments.<ref name=":1" /><ref>Template:Cite journal</ref> Besides the "5 Ps," the "3 As" can diagnose compartment syndrome in children: increasing anxiety, agitation, and analgesic needs.<ref>Template:Cite journal</ref> Normal compartment pressures in children are typically higher than adults.<ref>Template:Cite journal</ref> The most common cause of compartment syndrome in children is traumatic injury.<ref>Template:Cite journal</ref> In children <10 years of age, the cause is usually vascular injury or infection.<ref name="Shore 616–621">Template:Cite journal</ref> In children >14 years of age, the cause is usually due to trauma or surgical positioning.<ref name="Shore 616–621"/> Treatment for compartment syndrome in children is the same as adults.<ref name=":0" />

See also

• Abdominal compartment syndrome
• Escharotomy
• Ischemia-reperfusion injury of the appendicular musculoskeletal system

External links

• Compartment Syndrome of the Forearm – Orthopaedia.com
• Chronic Exertional Compartment Syndrome detailed at MayoClinic.com
• Template:DukeOrtho
• Template:MerckHome
• Compartment syndrome
• American Association of Orthopaedic Surgeons Compartment Syndrome