ARTICLE IN PRESSCurrent Orthopaedics (2004) 18, 468–476 www.elsevier.com/locate/cuorEMERGENCY CAREAcute compartment syndromeS. Singha,Ã, S.P. Trikhab, J. Lewisca 7 Ardmay Gardens, Surbiton, Surrey, KT6 4SW, UKb Flat 3, 9 Grange Road, Kingston-upon-Thames, Surrey, KT1 2QU, UKc Worthing and Southlands NHS Trust, West Sussex, UK KEYWORDS Summary Compartment syndrome can occur in any myofascial muscle compart- Compartment ment. If left untreated it can lead to ischaemic contractures and severe disabilities. syndrome; A high index of suspicion is required in at risk cases. Compartment pressure Volkmanns ischaemic monitoring is a useful adjunct in the diagnosis of raised compartment pressure contracture; especially when clinical assessment is difﬁcult. The key to a successful outcome is Fasciotomy; early diagnosis and decompression of affected compartments. Compartment & 2005 Elsevier Ltd. All rights reserved. pressure monitoringIntroduction muscle contracture of acute onset with increasing deformity despite splinting and passive exercises.Compartment syndrome has been deﬁned as ‘a Compartment syndrome is most commonly seencondition in which the circulation and function of following trauma, but may occur after ischaemictissues within a closed space are compromised by reperfusion injuries,3 burns4 and positioning duringan increased pressure within that space’.1 The surgery 5 Fractures of the tibial shaft and themuscles and nerves of the extremity are enclosed in forearm account for 58% of compartment syn-fascial spaces or compartments and are therefore dromes.6 A high index of suspicion is required andsusceptible to this condition. It is a surgical early decompression of all at risk compartments isemergency which if not recognised and treated the treatment of choice.7–9early can lead to ischaemic contractures, neurolo-gical deﬁcit, amputation, renal failure and evendeath. Richard von Volkmann was the ﬁrst to report Pathophysiologythis complication.2 He reported post-traumatic The common pathogenic factor in compartment syndrome is increased pressure within a fascial ÃCorresponding author. Tel.:+44 07968 013803; compartment. Three theories have been proposed to explain the development of tissue ischaemia:fax: +44 208 390 7029. E-mail addresses: firstname.lastname@example.org (S. Singh),email@example.com (S.P. Trikha), firstname.lastname@example.org (1) The increased compartmental pressure may(J. Lewis). lead to arterial spasm.100268-0890/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.cuor.2004.12.006
ARTICLE IN PRESSAcute compartment syndrome 469(2) The critical closing pressure theory states that Table 1 Aetiology of compartment syndrome as because of the small luminal radius and the high described by Matsen. mural tension of arterioles there must be a signiﬁcant transmural pressure difference (ar- Decreased compartment size teriolar pressure minus tissue pressure) to Closure of fascial defects maintain patency. If tissue pressure rises or Tight dressings arteriolar pressure drops so that this critical Localised external pressure Increased compartment content pressure difference does not exist then the Bleeding arterioles will close.11 Vascular injury(3) If tissue pressure rises then the veins will Bleeding disorder collapse due to their thin walls. If blood Increased capillary permeability continues to ﬂow from the capillaries the Post Ischaemic swelling venous pressure will rise until it exceeds tissue Exercise pressure and patency of the veins is re- Seizure and eclampsia established. This leads to an increase in venous Trauma pressure and therefore reduces the arteriove- Burns nous gradient and as a result reduces tissue Orthopaedic surgery blood ﬂow.12 Increased capillary pressure Exercise Venous obstruction The response of skeletal muscle to ischaemia or Muscle hypertrophytrauma is similar regardless of the mechanism of Inﬁltrated infusioninjury.13 When muscles become anoxic histamine- Nephrotic syndromelike substances are released and these dilate thecapillary bed and increase endothelial permeabil-ity. Transudation of plasma occurs into the intra-muscular compartment and this increases thepressure within the muscular compartment. To ment syndrome. See Table 1 for a list of aetiologiescompensate the lymphatic drainage increases, as described by Matsen1.however when this reaches a maximum theintracompartmental pressure (ICP) causes collapseof lymphatic vessels.14 Due to the high pressure inthe arterial system there is continuing blood ﬂow Diagnosisinto the compartment and this increases theswelling and oedema. It is only in the late stages Clinicalof compartment syndrome that arterial ﬂow intothe compartment is compromised. The key to successful treatment of acute compart- The amount of pressure required to produce a ment syndrome is early diagnosis and decompres-compartmental syndrome depends on many fac- sion of the affected compartments.1,7,9,23,24tors, including the duration of pressure elevation, The classical signs of impending compartmentmetabolic rate of tissues, vascular tone and the syndrome are pain, pallor, parasthesia, paralysismean arterial pressure. and pulselessness (The 5 p’s). However by the time The data on effects of ischaemia to tissues are all these symptoms have developed (especiallyderived from research in which sudden, total pulselessness) the limb will be non-viable.ischaemia was imposed. Neural tissues demonstrate A high index of suspicion is required to make thefunctional abnormalities (parasthesia and hyper- diagnosis. Clinical diagnosis is made on a combina-esthesia) within 30 min of the onset of ischaemia, tion of physical signs and symptoms. These includeand irreversible functional loss after 12 h.12,15–17 pain out of proportion to the stimulus, pain onMuscle shows functional changes after 2–4 h and passive stretch of the affected muscle compart-irreversible changes beginning at 4–12 h.16–18 ment, altered sensation, muscle weakness andIschaemia of 4 h gives rise to signiﬁcant myoglobi- tenderness over the muscle compartment. Thenuria, reaching a maximum at about 3 h although it symptoms and signs which are the most reliable incan persist up to 12 h.19–22 Compartment syndromes making the diagnosis are increasing pain, and painlasting longer than 12 h produce chronic functional on passive stretching of the muscle within thedeﬁcits, such as contractures, motor weakness and affected compartment.25–28 However these symp-sensory disturbance.23,24 Any cause of increased toms are subjective and impossible to elicit in thecompartmental pressure can result in a compart- unconscious, non-cooperative patient and those
ARTICLE IN PRESS470 S. Singh et al.who have had regional blocks. There has been blood leading to inaccurate readings. Due to theseconcern raised with the use of patient controlled potential draw backs a solid-state transducer (STIC)analgesia and regional anaesthesia in high risk intracompartment catheter has been developed.32cases.28,29 This has a multiperforated polyethylene tip with a STIC which can remain patent for up 16 h. The STICIntracompartmental pressures catheter has been shown to be functionally superior to conventional systems (needle, wick and slit) andPain can be unreliable especially in the trauma easier to assemble, calibrate, maintain and interpret.patient. It can range from being mild to severe, and The wick, slit and STIC methods require specia-in the unconscious patient important clinical lised equipment which may not be readily avail-symptoms and signs can be difﬁcult to elicit. able, while the needle system as proposed byTechniques have been developed to measure ICPs. Whitesides30 can be constructed from equipment which is readily available in most hospitals. If on clinical examination an obvious compart-Technique for monitoring intracompartmental ment syndrome is present pressure measurementpressures may not be necessary. However it can be usefulWhitesides 30 introduced a method for measuring adjunct in the diagnosis of compartment syndromeICP that required simple equipment available in especially in children, unconscious patients andmost hospitals (Fig. 1). Using a needle, plastic those with equivocal clinical ﬁndings.tubing ﬁlled with saline and air attached to amercury manometer they established tissue pres-sure measurement criteria as determinants of theneed for fasciotomy. However this technique At what pressure to decompress?involved the injection of saline into the compart-ment and this may aggravate an impending com- The normal tissue pressure within closed compart-partment syndrome. ments is about 0–10 mmHg. This pressure markedly The slit and wick techniques require a polyethy- increases in compartment syndrome. There islene tubing connected to a pressure transducer. inadequate perfusion and relative ischaemia whenThe tubing is ﬁlled with water and it is important the tissue pressure within a closed compartmentthat there are no air bubbles present within the rises to within 10–30 mmHg of a patient’s diastolictubing. The wick and slit catheter allow continuous blood pressure. Whitesides believed that fasciot-monitoring of compartments, and have been shown omy is indicated when the tissue pressure rises toto be more accurate than the needle manometer 40 mmHg in a patient with a diastolic pressure oftechnique.31 However the end of the tubing in the 70 mmHg. Using these criteria no functional deﬁcitsfascial compartment may become blocked with developed in patients, and all showed conclusive Figure 1 Apparatus for measuring compartment pressure.
ARTICLE IN PRESSAcute compartment syndrome 471evidence of compartment syndrome at the time of clinical studies relate to this region of the body.operation.30 McQueen 33 recommended a differential The site at which the compartment pressure ispressure (diastolic pressure minus ICP) of 30 mmHg measured should be within a few centimetres ofas a threshold for fasciotomy in tibial fractures. the maximal pressure as it cannot be assumed that ICPs between 30 and 50 mmHg have been the ICP equilibrates throughout the compart-suggested that a fasciotomy should be performed.34 ment.42 The pressure is always highest 5 cm fromThe lower level of 30 mmHg is most commonly used the fracture in tibial fractures, and therefore it isas when the tissue pressure rises above this the recommended that ICP should be measured as closecapillary pressure is insufﬁcient to maintain capil- to the site of injury as possible.43lary blood ﬂow. It has also been shown that fascial In the lower leg there are four fascial compart-compliance decreases sharply at an ICP of 33 mmHg ments and one or all of these may be involved inas the fascia has reached its maximum stretch.35 compartment syndrome. The highest pressures are It is important to state that tissue viability is recorded in the anterior compartment then thedependant on adequate perfusion and blood ﬂow deep posterior compartment.9,42 It would seemwithin the microcirculation. Setting an absolute logical therefore in tibial fractures to measure thepressure ignores the role that blood pressure plays pressure within 5 cm of the fracture and to monitorin maintaining adequate blood ﬂow within a the pressure in the anterior tibial compartment.compartment. It has been shown that muscle However other compartments may need to bedamage occurring at a speciﬁc level relative to monitored depending on the clinical picture.the blood pressure is more consistent that relying Within the UK practices for monitoring ICP vary.on a ﬁxed compartment pressure.36 In a postal questionnaire 46% of trauma centres had The diastolic pressure minus the ICP is called the equipment available for monitoring compartmentdelta pressure. The critical level has been found to pressures, and 42% of respondents were unsure atrange from 10 to 35 mmHg. The most commonly what ICP they would perform fasciotomies. Only 9%used delta pressure is 30 mmHg or less.1,10,33 In used a delta pressure of 30 mmHg as a guide totibial fractures it has been shown that by using a perform fasciotomies as suggested by Whitesides 30delta pressure of 30 mmHg unnecessary fascio- and McQueen.33tomies can be avoided. No clinically signiﬁcant Failing to diagnose and treat a compartmentcomplications were identiﬁed in patients with a syndrome urgently can be disastrous for patients.delta pressure greater than 30 mmHg. Pressure monitoring can be a useful adjunct to help The ICP or delta pressure at one point in time conﬁrm the diagnosis. McQueen et al. 37 suggestdoes not necessarily conﬁrm that a compartment monitoring all patients at risk as an aid to clinicalsyndrome is present. During intramedullary nailing diagnosis. Others have suggested that this can leadthere are short increases in ICP, however these are to over treatment.44 Certainly pressure monitoringnot always associated with clinical signs of com- should be used in unconscious patients, those whopartment syndrome.37 The higher the ICP and the are difﬁcult to assess and when equivocal clinicallonger it is maintained the greater the muscle ﬁndings are present. All centres involved in traumadamage, however an ICP of 30 mmHg maintained should have equipment available for monitoringfor 8 h caused signiﬁcant muscle necrosis in canines compartment pressures and clinicians involved in35 and biochemical changes have been observed in trauma need to be aware of interpretation of thesethe experimental situation with a delta pressure of results.20 mmHg for 4 h. When the delta pressure ap-proached zero these changes were present in 2 h.38 As stated earlier the sooner the decompression Other methods for measuring compartmentthe better the outcome. If decompression is pressuresdelayed for more than 12 h permanent disabilitymay occur, however if decompression is performed Near-Infrared Spectroscopy (NIRS)under 6 h of making the diagnosis a full recovery NIRS is an optical technique that allows tracking ofcan be expected.24,25,39,40,41 However conﬁrming variations in the oxygenation of muscle tissue.45the exact time of the start of compartment The technique involves monitoring the absorptionsyndrome can be difﬁcult. of light transmitted through muscle tissue at two distinct wavelengths. A change in the oxygenationProblems with interpreting pressures state of haemoglobin results in opposite changes in the absorption of light. By calculating the differ-The majority of compartment syndromes occur in ences in the absorption signal the device provides athe lower limb and hence the majority of the continuous index of tissue oxygenation. It can be of
ARTICLE IN PRESS472 S. Singh et al.use in investigating chronic compartment syndrome ICP adequate decompressive fasciotomies should bein adults, as it can detect changes in relative performed.oxygenation, but it is of little value in acute Several surgical approaches have been tried incompartment syndrome as changes in the relative the leg. The surgical goal is the prevention ofoxygenation may have already occurred.46 permanent disability, and the adequacy of decom- pression should not be compromised by cosmesis orLaser Doppler ﬂowmetry the number and lengths of incisions. It is essentialThis uses a ﬂexible ﬁbre optic wire which is to decompress all compartments at risk.introduced into the muscle compartment. The In the lower limb ﬁbulectomy via a single lateralsignals from this wire are recorded on a computer. incision has been suggested, however this onlyIt can be used as an adjunct in the diagnosis of allows limited views and an adequate release maychronic compartment syndrome,47 however it was not be achieved. A two incision approach allowssuggested that further work needs to be carried out safe access to all four compartments of the lowerinto the pathophysiology of chronic compartment leg and is the treatment of choice. The deepsyndrome and laser Doppler ﬂowmetry needs posterior compartment has been neglected inanalysis in larger population groups. descriptions of fasciotomies however this is the 2nd most commonly involved compartment and access can be gained behind the posteromedial border of the tibia in the distal third of the legTreatment where the belly of ﬂexor digitorum longus is exposed.Raised ICP threatens the viability of the limb and The technique of double incision fasciotomy isthis represents a true management emergency. As described below. It is important to perform astated earlier early diagnosis is the key to a complete decompression and incisions less thansuccessful outcome. 15 cm may result in inadequate decompression.49 In Removal of all dressing down to skin, followed by the emergency treatment of compartment syn-open extensive fasciotomies with decompression of drome there is no place for short cosmeticall muscle compartments in the limb is the incisions.treatment of choice. Experimental evidence shows that the circularcast can substantiate the adverse effects of raised Lower limb fasciotomy (Fig. 2)ICP.48 Splitting of the cast on one side led to an Anterolateral incision. This incision allows ap-average fall in ICP 30%, and 65% if split on both proach to the anterior and lateral compartments ofsides. Splitting of the padding led to a further fall in the leg. A 15–20 cm incision is placed halfwayICP by 10%. Complete removal of the cast reducedthe pressure by another 15%. In patients whom the diagnosis is being consid-ered and in those in whom resuscitation isproceeding the following steps should be per-formed:14(1) Ensure the patient is normotensive, as hypoten- sion reduces perfusion pressure and facilitates tissue injury,(2) Remove any circumferential or constricting bandages as these may increase ICP,(3) Maintain the limb at heart level as elevation reduces the arterio-venous pressure gradient.(4) Give supplemental oxygen to ensure optimal saturation. Figure 2 The safe incisions. These are designed to avoidFasciotomies the perforating arteries. The antero-lateral incision is 2 cm lateral to the medial border of the tibia. TheIf the tissue pressure remains elevated despite the postero-medial incision is 1 or 2 cm prosterior to theabove, and the clinical scenario indicates increased medial border of the tibia.
ARTICLE IN PRESSAcute compartment syndrome 473Figure 3 Anterior and peroneal compartment decom- Figure 4 Decompression of the posterior compartmentspression (ac—anteriror compartment; Ic—lateral com- (s—soleus; g—gastrocneumius; tp—tibialis posterior).partment). The fascia is shown in dark grey.between the ﬁbula and the tibial crest. The skin A technique for forearm fasciotomy is nowedges are undermined. A short longitudinal incision described.is made over the muscle bellies allowing palpationof the intramuscular septum between the anterior Forearm fasciotomyand lateral compartments. By identifying the A single incision can be used to decompress theseptum the superﬁcial peroneal nerve can be volar aspect of the forearm (Fig. 5). It is similar toidentiﬁed adjacent to the septum where it crosses the volar approach to the radius as described bythe junction of the middle and distal thirds of the Henry.50 It begins 1 cm proximal and 2 cm lateral toleg. The anterior compartment fascia is opened the medial epicondyle. It is carried obliquely acrossthroughout the leg by extending the ﬁrst incision in the antecubital fossa and over the volar aspect ofthe fascia (Fig. 3). It is important not to damage the mobile wad of three muscles (brachioradialis,the superﬁcial peroneal nerve in the distal third of extensor carpi radialis longus and extensor carpithe wound. The peroneal compartment is decom- radialis brevis). It is curved medially reaching thepressed by incising the fascia in line with the ﬁbular midline at the junction of the middle and distalshaft posterior to the intermuscular septum. third of the forearm. It is continued straight distallyProximally the incision is directed to the ﬁbular to the proximal skin crease over palmaris longus.head and distally to the lateral malleolus remaining The incision is curved across the wrist crease to theposterior to the superﬁcial peroneal nerve. mid palm area. The median nerve should be decompressed at the carpal tunnel. In cases ofPosteromedial incision. This incision is used to median nerve symptoms the median nerve shoulddecompress the superﬁcial and deep posterior also be explored in the proximal forearm. Thecompartments of the leg. It is placed 2 cm posterior median nerve can be constricted at the proximalto the posterior tibial margin and is about 15–20 cm end of pronator teres and at the proximal edge oflong. Care should be taken to avoid damage to the ﬂexor digitorum superﬁcialis.saphenous nerve and vein and they should be The dorsal muscle compartment can be releasedretracted anteriorly. The superﬁcial posterior com- by a single incision. This begins 2 cm distal to thepartment is decompressed ﬁrst, and the fascia is lateral epicondyle and carried distally to the wrist.incised throughout its length (Fig. 4). The Achilles The skin edges are undermined and the dorsaltendon helps to identify this compartment. The fascia incised directly in line with the skin incision.fasciotomy is extended distally as far as the medialmalleolus. The deep posterior compartment is then Foot fasciotomiesreleased by incising the fascia distally and then Excessive bleeding and oedema can produce com-proximally under the bridge of soleus. It may be partment syndromes in the closed spaces of thenecessary to detach the soleus from the back of foot. Foot compartment syndrome should bethe tibia. suspected in all crushing and high energy foot
ARTICLE IN PRESS474 S. Singh et al. wound.53 Closure of the wound takes about 10 days. There are some commercially available devices to aid fasciotomy closure.54 The Suture Tension Adjustment Reel (STAR) is placed parallel to the wounds at the time of fasciotomy, and when the swelling has subsided the reels are tightened to gradually close the wound. This method requires 2–4 days of bedside tightening for wound closure. Split skin grafting can lead to a poor cosmetic result, with insensate skin and donor site morbidity. Delayed primary closure using the skin’s elasticity provides a more cosmetically acceptable outcome for the patient but requires greater nursing care. However a poor cosmetic result is preferable to the outcome of a missed compartment syndrome.Figure 5 The incision for decompression of the volar Intramedullary nailingaspect of the forearm. If posterior compartment pressuredoesn’t concomitantly fall then the posterior compart- Over the last 2 decades intramedullary nailing ofment requires to be opened by an additional linear tibial fractures has increased. Initially there wasposterior incision. concern that nailing may increase ICPs and pre- cipitate compartment syndrome and it was thought that nailing should be delayed for up to 7 days to allow the swelling to subside.55 Further research ininjuries. With crush injuries of the foot Myerson this area has shown that during reaming thefound acute compartment syndrome in 16 of 58 pressure may rise to 180 mmHg,37 however thispatients.51 Tense swelling of the foot should alert high ICP fell back to normal after removing thethe clinician to this possibility, particularly because reamer. The application of traction also increasespain on passive stretch of the toes and the presence ICPs but these immediately dropped with release ofor absence of pedal pulses are less reliable the traction. Despite high pressures being reachedindications of compartment syndrome in the foot. during the reduction of tibial fractures and duringThere are a number of different approaches to reaming no patients in the study developed anydecompress foot compartments. A dorsal approach sequelae of compartment syndrome. Transientalong the 2nd and 4th metatarsals is simple to increases in compartment pressures seam to beperform and provides effective decompression of well tolerated and return back to normal after theall four compartments.52 Associated Lisfranc in- stimulus is removed.juries and metatarsal fractures can also be stabi- Controversy still exists if monitoring should belised via this approach. performed during intramedullary nailing. McQu- een9,33 advocates routine monitoring of all patients with tibial fractures if facilities are available.Closure of fasciotomy wounds Others have suggested that this may lead to over treatment44 and unnecessary fasciotomies.After decompression of fascial compartments thewounds are left open and sterile dressings areapplied. Delayed primary closure can be performedwhen swelling has subsided, however this may be Conclusiondifﬁcult due to skin retraction and oedema. If thewound edges cannot be approximated without Compartment syndrome can have disastrous con-tension, skin grafting may be required. sequences if not recognised and treated appro- Various methods have been described using the priately. In conscious patients the diagnosis can beelastic properties of the skin to aid fasciotomy made by careful examination of the patient.closure. Invasive monitoring is a useful adjunct especially An elastic vessel shoelace can be applied with in unconscious patients and those who are difﬁcultthe staples at the side of the wound. This can be to assess. As the tissue pressure rises the viability ofgradually tightened without the need for anaes- the cells are threatened. The tissue pressure levelthesia, providing gradual closure of the fasciotomy at which perfusion threatens cell viability varies
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