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Compartment syndrome

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Compartment syndrome

Classification and external resources

ICD-10 M62.2, T79.6

ICD-9 729.7, 958.9

DiseasesDB 3028

MedlinePlus 001224

eMedicine emerg/739

MeSH D003161

Compartment syndrome is a painful condition that can occur within some of the muscle groups within the body. When there is insufficient blood supply to muscles and nerves due to increased pressure within one of the body's compartments, such as an arm, leg or other enclosed space within the body. If uncorrected, the lack of blood supply leads to injury in the affected muscles and nerves.[1] The two different variations of compartment syndrome are classified as either acute or chronic. Acute compartment syndrome is due to an injury or trauma, whereas chronic compartment syndrome, also known as chronic exertional compartment syndrome (CECS) is from a repetitive movement or action, typically occurring in athletes.

Contents [hide] 1 Signs and symptoms 2 Causes 3 Pathophysiology 4 Diagnosis 5 Treatment 5.1 Acute compartment syndrome 5.2 Subacute compartment syndrome 5.3 Chronic compartment syndrome

6 Complications 7 Notable cases 8 See also 9 References 10 Further reading 11 External links

Signs and symptoms[edit]

Classically, there are 6 "Ps" associated with compartment syndrome — pain out of proportion to what is expected based on the physical exam findings, paresthesia, pallor, paralysis, pulselessness, and poikilothermia. One should not solely rely on these symptoms to confirm compartment syndrome. Pain, severe and persistent, is the only one that is always reliable, and is typically the first symptom felt, especially when stretching or flexing the muscles. Other common symptoms of acute compartment syndrome are tightness of the muscle, an unusual sensation on the skin such as numbness or tingling, and swelling. Numbness of the muscle and sometimes paralysis will be late signs of the syndrome[24]. Sometimes bruising of the area may be noticed[19]. Pain is often reported early and almost universally. The description is usually of exquisite, deep, constant, and poorly localized pain out of proportion with the findings on physical examination (often incorrectly described as pain out of proportion to the injury). The pain is aggravated by passively stretching the muscle group within the compartment or actively flexing it (though this finding is not specific to compartment syndrome alone) and is not relieved by analgesia up to and including morphine.

Causes[edit]

Because the fascia layer that defines the compartment 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. Common causes of acute compartment syndrome include tibial or forearm fractures, ischemic reperfusion following injury, hemorrhage, vascular puncture, intravenous drug injection, casts, prolonged limb compression, crush injuries and burns.[4][5]. Less common causes include labor and delivery following uncomplicated births and csections (author=Bayar A, et. al 2007)(author=Radosa J, et.al 2011). This is usually not an emergency, but the loss of circulation can cause temporary or permanent damage to nearby nerves and muscles. If acute compartment syndrome is bad enough in the abdomen, then organs such as the kidneys, liver, and bowel can be permanently damaged. Due to the surrounding muscles increased pressure, blood cannot move into and out of the organs properly. This is where compartment syndrome can, but not necessarily will become life threatening. The cause of compartment syndrome is due to excess pressure on or within the muscle compartments. This pressure can occur for many different reasons, many are due to injuries. Injuries cause the swelling of tissue. The swelling of the tissue forces pressure upon the muscle compartments, which has a limited volume. Due to this pressure, the venules and lymphatic vessels that drain the muscle compartments are compressed, and are prevented from draining or taking oxygenated blood into the compartment. The oxygen in the blood is necessary to keep the tissues and muscles alive. As arterial inflow continues while outflow is decreased, the pressure builds up in the muscle compartments. This pressure will eventually decrease the amount of blood flow over the capillary bed, causing the tissue to become ischaemic. The tissues will release factors and will lead to the formation of edema.

Chronic compartment syndrome, also known as chronic exertional compartment syndrome (CECS), is brought on by repetitive exercise. It happens frequently with runners, cyclists, and swimmers. According to Touliopolous, CECS of the leg is a condition caused by exercise which results in increase tissue pressure within a limited fibro - osseous compartment - muscle size may increase by up to 20% during exercise (Touliopolous, 1999) When this happens pressure builds up in the tissues and muscles causing tissue ischemia (Touliopolous, 1999). An increase in muscle weight will reduce the compartment volume of the surrounding fascial borders and resulting in an increase of intracompartmental pressure.[7] An increase in the pressure of the tissue can cause fluid to exude into the small spaces between the tissue known as interstitial space, leading to a disruption of the micro-circulation of the leg.[7] This condition occurs commonly in the lower leg and various other locations within the body, such as the foot or forearm[18]. This is commonly seen in athletes who train rigorously in activities that involve constant repetitive actions or motions[17]. Symptoms involve numbness or a tingling sensation in the area most affected[18]. Other signs and symptoms include pain described as aching, tightening, cramping, sharp, or stabbing.[7] This pain can occur for months, and in some cases over a period of years, and are often relieved by rest.[7] It also includes moderate weakness that can be a noticeable factor in the affected region[18]. Chronic exertional compartment syndrome most commonly affects the anterior compartment of the leg, this can lead to problems with dorsiflexion of the ankle and the toes.[8] The symptoms of CECS are often confused with more common injuries like shin splints and spinal stenosis.[8] Treatment for chronic exertional compartment syndrome includes decreasing or subsiding exercising and activities, or cross training for athletes. Another form of treatment is a fasciotomy, preventing the pressure from building up in the compartments.[17]

Pathophysiology[edit]

During compartment syndrome there is increased intra-compartmental pressure in the interstitium over its capillary perfusion pressure, due to the accumulation of necrotic debris and haemorrhage, especially haemorrhage secondary to fractures (Rorabeck, 1984). Any condition that results in an increase in compartment contents or reduction in a compartment’s volume can lead to the development of an acute compartment syndrome. When pressure is elevated, capillary blood flow is compromised. Edema of the soft tissue within the compartment further raises the intra-compartment pressure, which compromises venous and lymphatic drainage of the injured area. Pressure, if further increased in a reinforcing vicious circle, can compromise arteriole perfusion, leading to further tissue ischemia. Untreated compartment syndrome-mediated ischemia of the muscles and nerves leads to eventual irreversible damage and death of the tissues within the compartment. There are three main mechanisms that are hypothesized to cause compartment syndrome. One idea is the increase in arterial pressure (due to increased blood flow due to trauma or excessive exercise) causes the arteries to spasm and this causes the pressures in the muscle to increase even further. Second, obstruction of the microcirculatory system is hypothesized. Finally, there is the idea of arterial or venous collapse due to transmural pressure.

Acute compartment syndrome (ACS) of the lower extremity is a clinical condition that is seen fairly regularly in modern practice (Shagdan, 2010). Although pathophysiology of the disorder is well known to physicians who care for patients with musculoskeletal injuries, the diagnosis is often difficult to make (Shagdan, 2010). If left untreated, acute compartment syndrome can lead to more severe conditions including rhabdomyolysis and kidney failure potentially leading to death.

Diagnosis[edit]

Compartment syndrome is a clinical diagnosis. Some of the physical signs a doctor will first look for is pain when touched or flexing the muscles- especially the foot when compartment syndrome is in the lower leg- and swelling in the area. However, it can be tested for by gauging the pressure within the muscle compartments. In order to measure the pressures within the compartments, a large needle is connected to a device that will be able to read the pressure. In the case of acute compartment syndrome only one test should need to be conducted, but with chronic compartment syndrome a test before and after the activity that inflicts pain needs to be doneundefined. If the pressure is sufficiently high, a fasciotomy will be required to relieve the pressure. Various recommendations of the intracompartmental pressure are used with some sources quoting >30 mmHg[3] as an indication for fasciotomy while others suggest a <30 mmHg difference between intracompartmental pressure and diastolic blood pressure.[9] This latter measure may be more sensible in the light of recent advances in permissive hypotension, which allow patients to be kept hypotensive in resuscitation. It is now relatively easy to measure compartment and subcutaneous pressures using the pressure transducer modules (with a simple intravenous catheter and needle) that are attached to most modern anaesthetic machines. Most commonly compartment syndrome is diagnosed through a diagnosis of its underlying cause and not the condition itself. According to Blackman one of the tools to diagnose compartment syndrome is X-ray to show a tibia/fibula fracture, which when combined with numbness of the extremities is enough to confirm the presence of compartment syndrome.[10]

Treatment[edit]

Acute compartment syndrome[edit]

Acute compartment syndrome is a medical emergency requiring immediate surgical treatment, known as a fasciotomy, to allow the pressure to return to normal and prevent compartment syndrome from ever occurring again in those specific compartments. It is an emergency because too much damage can lead to amputation or death. Nerve damage after six hours of suffering compartment syndrome can lead to permanent, irreversible damage. Typically, regardless of the number of compartments affected, all compartments in the same area will be released through a fasciotomy. For instance, if only the deep posterior compartment of a leg is affected, the treatment would be fasciotomy, with medial (inside of leg) and lateral (outside of leg) incisions to release all compartments of the leg in question, namely the anterior, lateral, superficial posterior and deep posterior.[11] An acute compartment syndrome has some distinct features such as swelling of the compartment due to inflammation and arterial occlusion. Decompression of the nerve traversing the compartment might alleviate the symptoms (Rorabeck, 1984).

Chronic compartment syndrome[edit]

Chronic compartment syndrome is not an emergency, but rather a nuisance to athletes. Chronic compartment syndrome in the lower leg can be treated conservatively or surgically, or left alone since it is a self limiting condition[23]. Conservative treatment includes rest, anti-inflammatories, and manual decompression. Elevation of the affected limb in patients with compartment syndrome is contraindicated, as this leads to decreased vascular perfusion of the affected region. Ideally, the affected limb should be positioned at the level of the heart. The use of devices that apply external pressure to the area, such as splints, casts, and tight wound dressings, should be avoided.[12] In cases where symptoms persist, the condition can be treated by a surgical procedure, subcutaneous fasciotomy or open fasciotomy. Left untreated, chronic compartment syndrome can develop into the acute syndrome. A possible complication of surgical intervention for chronic compartment syndrome can be chronic venous insufficiency.

Hyperbaric oxygen therapy has been suggested by case reports — though as of 2011 not proven in controlled randomized 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.[13][14] The main treatment for compartment syndrome is surgical. Incisions are made in the affected muscle compartments so that they will decompress. This decompression will relieve the pressure on the venules and lymphatic vessels, and will increase bloodflow throughout the muscle.

Complications[edit]

Failure to relieve the pressure can result in necrosis of tissue in that compartment, since capillary perfusion will fall leading to increasing oxygen deprivation of those tissues. This can cause Volkmann's contracture in affected limbs. As intercompartmental pressure rises during compartment syndrome, perfusion within the compartment is reduced leading to ischemia, which if left untreated, results in necrosis of nerves and muscles of the compartment (Shears, 2006). Rhabdomyolysis and subsequent renal failure are also possible complications. As mentioned above, both amputation and death are possibilities depending on the severity of acute compartment syndrome.

Notable cases[edit]

PBS science correspondent Miles O'Brien suffered a compartment syndrome and had to have his left arm amputated.[15] According to his blog, O'Brien was securing cases filled with camera gear on a cart as he wrapped up a reporting trip to Japan and the Philippines. One fell on his arm. The arm was sore and swollen the next day but worsened on the next, Feb. 14, 2014 and he sought medical care. At the hospital, as his pain increased and arm numbness set in, a doctor recommended an emergency procedure to relieve the pressure within the limb, O'Brien wrote. The doctor made a real-time call and amputated his arm just above the elbow.

See also[edit] Volkmann's contracture Abdominal compartment syndrome

References[edit]

1.Jump up ^ MedicineNet.com URL: http://www.medicinenet.com/compartment_syndrome/article.htm Accessed 12 December 2012 2.Jump up ^ "Compartment Syndrome: Fractures, Dislocations, and Sprains: Merck Manual Professional". 3.^ Jump up to: a b "emedicine: compartment syndrome". 4.Jump up ^ Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ (December 2007). "Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective". Am Surg 73 (12): 1199–209. . 5.Jump up ^ Maerz L, Kaplan LJ (April 2008). "Abdominal compartment syndrome". Crit. Care Med. 36 (4 Suppl): S212–5. doi:10.1097/CCM.0b013e318168e333. . 6.Jump up ^ Verleisdonk EJ (October 2002). "The exertional compartment syndrome: A review of the literature". Ortop Traumatol Rehabil 4 (5): 626–31. . 7.^ Jump up to: a b c d e "Exercise induced compartment syndrome in a professional footballer". Bjsm.bmj.com. 2004-04-01. Retrieved 2014-03-08. 8.^ Jump up to: a b Posted on Thu, Dec 02, 2010 @ 11:33 AM (2010-12-02). "Exercise Induced Compartment Syndrome". Foundrysportsmedicine.com. Retrieved 2014-03-08. 9.Jump up ^ Pocketbook of Orthopaedics and Fractures: Ronald McRae 10.Jump up ^ Blackman PG (March 2000). "A review of chronic exertional compartment syndrome in the lower leg". Med Sci Sports Exerc 32 (3 Suppl): S4–10. . 11.Jump up ^ Salcido R, Lepre SJ (October 2007). "Compartment syndrome: wound care considerations". Adv Skin Wound Care 20 (10): 559–65; quiz 566–7. doi:10.1097/01.ASW.0000294758.82178.45. . 12.Jump up ^ Meyer RS, White K, Smith J, Groppo E, Mubarak S, Hargens A (October 2002). "Intramuscular and blood pressures in legs positioned in the hemilithotomy position". J Bone and Joint Surgery 84–A (10): 1829–35. 13.Jump up ^ Undersea and Hyperbaric Medical Society. "Crush Injury, Compartment syndrome, and other Acute Traumatic Ischemias". 14.Jump up ^ Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P (August 1996). "Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo-controlled clinical trial". J Trauma 41 (2): 333–9. doi:10.1097/00005373-199608000-00023. . 15.Jump up ^ "PBS science correspondent Miles O'Brien recounts amputation". Fox News. 2014-02-25. Retrieved 2014-03-08.

17 "Compartment Syndrome -OrthoInfo - AAOS." Compartment Syndrome -OrthoInfo - AAOS. N.p., n.d. Web. 07 Dec. 2013.

18. Paik, Ronald S., Douglas Pepples, and Mark R. Hutchinson. "Chronic exertional compartment syndrome." pain 78 (2007): 136-42. 19. WebMD. URL: http://www.webmd.com/pain-management/guide/compartment-syndrome-causes-treatments 20. Patient.co.uk. 2011, March 18. http://www.patient.co.uk/doctor/compartment-syndrome 21. MedlinePlus. 2012, August 11. URL: http://www.nlm.nih.gov/medlineplus/ency/article/001224.htm 22. Wiesel, Sam W. "Operative Techniques in Orthopedic Surgery Volume 1." 2012. 23. British Journal of Sports Medicine. "Diagnosis and management of chronic compartment syndromes: a review of the literature." 1997, March. 24. Jagminas, Liudvikas MD. "Compartment Pressure Measurement." 2013, June 4.

Further reading[edit] Ahmet Bayar, MD; Selcuk Keser, MD; Mubin Hosnuter, MD; H. Alper Tanriverdi, MD; Ahmet Ege, MD. "Lower Limb Compartment Syndrome After an Uncomplicated Labor". Orthopedics. November 2007 - Volume 30 · Issue 11 Floyd R. and Thompson C. Manual of Structural Kinesiology 17th Ed., McCrawHill. ISBN 978-0-07-337643-1 Blackman, Paul G.. "A review of chronic exertional compartment syndrome in the lower leg." Medicine and Science in Sports and Exercise 32.3 (supp): S4-S10. Hamill, J and Knutzem KM. Biomechanical Basis of Human Movement, 3rd Ed. Lippincott Williams&Wilkins. ISBN 978-0-7817-9128-1 Leung, Y.F., Ip, S.P., Chung, O.M., Wai, Y.L., (2003, June). Unimuscular neuromuscular insult of the leg in partial anterior compartment syndrome in a patient with combined fractures. Hong Kong Medical Journal, 9. Rankin, E.A., Andrews, G. (1981, December). Anterior tibial compartmental syndrome: an unusual presentation. Journal of the National Medical Association, 73. Rorabeck, C.H., (1984, January). The treatment of compartment syndromes of the leg. Journal of Bone and Joint Surgery-British, 66-B. Retrieved from http://web.jbjs.org.uk/cgi/content/abstract/66-B/1/93 Shadgan, B., et al. (2010, October). Current thinking about acute compartment syndrome of the lower extremity, Canadian Journal of Surgery, 53. Shears, E., Porter, K. (2006). Acute compartment syndrome of the limb. Trauma, 8. Touliopolous, S., Hershman, E.B., (1999, March). Lower leg pain: diagnosis and treatment of compartment syndromes and other pain syndromes of the leg. Sports Medicine, 27.

External links[edit] Compartment Syndrome of the Forearm - Orthopaedia.com Chronic Exertional Compartment Syndrome detailed at MayoClinic.com Compartment_syndrome at the Duke University Health System's Orthopedics program 05-062a. at Merck Manual of Diagnosis and Therapy Home Edition Fasciotomy, Chronic Venous Insufficiency, and the Calf Muscle Pump Compartment syndrome Saphenous nerve injury after fasciotomy for compartment syndrome American Association of Orthopaedic Surgeons Compartment Syndrome