Injury, Int. J. Care Injured (2005) 36, 992—998 www.elsevier.com/locate/injuryERRATUMAcute compartment syndrome of the limbW. Kostler *, P.C. Strohm, N.P. Sudkamp ¨ ¨Department fur Orthopadie und Traumatologie, Klinik fur Traumatologie, Universitatsklinikum Freiburg, ¨ ¨ ¨ ¨Hugstetterstr. 55, 79106 Freiburg im Breisgau, GermanyAccepted 15 April 2004 KEYWORDS Summary In this review the aetiology, clinical signs, diagnosis and therapy of the Compartment; acute compartment syndrome of the limb is discussed. It is a limb- and untreated life Compartment threatening emergency. For good results, early detection is necessary. It is important syndrome; to educate those taking care of patients of risk, especially in the early symptoms and Fracture complications signs. In uncooperative, unconscious and sedated patients pressure monitoring is recommended. The critical level of the absolute intracompartmental pressure is unclear. It is recommended to use a delta p pressure of 30 mmHg. Below this pressure in the presence of clinical signs a fasciotomy of all compartments is the treatment of choice. # 2004 Elsevier Ltd. All rights reserved.Introduction abdominal pressure alters cardiovascular haemody- namics, respiratory mechanics and renal function.Matsen deﬁned the compartment syndrome as ‘‘a In this review, only the aetiology, clinical signs,condition in which increased pressure within a lim- diagnosis and treatment of the limb compartmentited space compromises the circulation and function syndromes are discussed.of the tissues within that space.’’24 Malgaigne was the ﬁrst to describe compartmentsyndrome, and the ﬁrst medical reference was by Aetiology and incidenceVolkmann39 in 1881. Jepsen reported successfultreatment by decompression18 in an experimental Most compartment syndromes are associated withstudy. traumatic insults, but the condition also occurs after The abdominal compartment syndrome was ﬁrst reperfusion, following a period of ischaemia, burns,described by Baggot in 1951.4 The increasing intra- prolonged limb compression after drug abuse or poor positioning during prolonged surgical proce- DOI of original article: 10.1016/j.injury.2004.04.009 dures (Table 1). * Corresponding author. Tel.: +49 761 270 2401;fax: +49 761 270 2520. This classiﬁcation, based on aetiology, is a sim- E-mail address: email@example.com pliﬁcation; in most cases, a combination of factors is(W. Kostler). ¨ responsible.11,370020–1383/$ — see front matter # 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2005.01.007
Acute compartment syndrome of the limb 993 Table 1 Causes of acute compartment syndromes Iatrogenic Orthopaedic Fractures and fracture surgery Vascular Arterial and venous injuries The use of a pneumatic antishock garment, or mili- Reperfusion injury tary antishock trousers, may also lead to compart- Haemorrhage ment syndrome. In combination with hypotension, Phlegmasia caerulea dolens normally the reason for its use, and with application Soft tissue Crush injury for more than 30 min, the development of compart- Burns ment syndrome should be borne in mind.2 Prolonged limb compression Prolonged surgery, especially in the Trendelen- Iatrogenic Puncture in anticoagulated patients burg position, sometimes causes compartment syn- Use of a pneumatic antishock garment Casts and circular dressings dromes.7 In combination with poor positioning, it Pulsatile irrigation can also cause soft tissue necrosis, as a result of Occasional Snakebite direct pressure. Overuse of muscles Pathophysiology The normal pressure in the muscle compartments isOrthopaedic below 10—12 mmHg (4—21).42 The compartmental perfusion pressure, which is the mean arterialThe most common fractures causing a limb pressure minus the compartment pressure, shouldcompartment syndrome are those of the tibial be above 70—80 mmHg.17,23. Both increasingshaft (40%) and of the forearm (18%). About 23% the compartmental pressure and decreasing theare caused by soft tissue injuries without frac- perfusion pressure can lead to a compartmentture.27,33 syndrome. Swelling of the injured muscle and The incidence after closed tibial fractures ranges soft tissue raises the intra-compartmental pres-from 1 to 29%, while in open fractures, it is between sure, closing the lymphatic vessels and the small1 and 10%. A greater incidence in multifragmentary venules. Hypertension in the capillary bed and thefractures is a reﬂection of the higher energy causing compression of the arterioles in the later stagesthis type of fracture, resulting also in a more severe leads to an ischaemia, which further increases thesoft tissue injury. pressure, and a vicious downward spiral becomes It is important to recognise that open fractures established.can also develop a compartment syndrome, both in In the reperfusion situation, there is a complexthe closed compartments and those compartments mechanism leading to vascular leakage. Althoughopened by the injury. some factors, such as leucotrienes, tumour necrosis factor, free radicals and others, are known to play a part, the exact mechanism within the cell remainsVascular unclear.10 The ischaemia causes perifascicular and intra-Any procedure revascularising the limb can result in fascicular oedema in the early stage presentation,a muscle compartment syndrome, the incidence which, without treatment, leads to atrophy andranging between 0 and 21%. In patients with com- necrosis of the muscle ﬁbres. The end result of anbined popliteal artery and venous injuries, more unchecked compartment syndrome includes neuro-than 50% require a fasciotomy.36 logical deﬁcit, muscle necrosis and late ﬁbrous contractures.Soft tissue Symptoms and signsSwelling of the soft tissue develops in contusioninjury without fracture, especially in patients with The initial clinical signs of compartment syndromea coagulopathy. Burns can also cause compartment are often subtle. Early diagnosis requires a highsyndrome. index of suspicion. Pain, usually out of proportion In patients with altered consciousness due to to the injury, can be the ﬁrst indication of compart-drug or alcohol abuse, prolonged limb compression ment syndrome. The six P’s, formerly emphasised bycan lead to soft tissue injury and compartment Mubarak and Rorabeck, are very late signs, usuallysyndrome. at an irreversible stage29 (Table 2).
994 W. Kostler et al. ¨ Table 2 Symptoms and signs of acute compartment the foot, its motor function being ﬂexion of the toes. syndrome37 The superﬁcial posterior compartment can be exam- Pain (spontaneous and disproportionate)20,33 ined by testing sural nerve sensation along the Pain on passive stretching of the involved muscles31,33 lateral border of the foot. Swollen and tense compartment12,15 Rapid progression of these signs over a short time period Diagnosis Paraesthesia (initially affecting two point discrimina- tion)13,43 For a good clinical outcome, early diagnosis is of Pulselessness (usually in vascular injury)15,21 paramount importance. In patients with early symp- Paralysis (late symptom) toms, such as increasing pain, paraesthesiae and pain on passive stretching, careful and frequent Remember that these signs can be elicited only in assessment is necessary. If this is impossible, thenthe fully conscious patient. Early diagnosis is difﬁ- prophylactic fasciotomy may well be indicated. It iscult in patients with CNS compromise, the very certainly recommended in patients with an inter-young and the very old, and in patients with sub- rupted arterial supply lasting more than 4—6 h, instance abuse. To distinguish between ischaemic pain patients who are unconscious, or have peripherealand pain caused by a fracture, contusion, or muscle nerve injuries, and in patients who undergo openinjury can sometimes be very difﬁcult. The presence fracture ﬁxation near a compartment at risk.of distal pulses never excludes compartment syn-drome. In the leg, with its four compartments (anterior, Laboratory parameterslateral, deep posterior and superﬁcial posterior),the deep peroneal nerve lies in the anterior com- Seriously elevated levels of creatinine phosphoki-partment (Fig. 1). Its sensory territory is conﬁned to nase (CPK) may indicate severe muscle damage, orthe web space between the ﬁrst and the second toes ischaemia. In absence of clinical signs, it couldand it subserves active dorsiﬂexion of the toes. The indicate an unsuspected compartment syndrome.superﬁcial peroneal nerve runs through the lateral For early diagnosis, it is clearly not helpful.compartment and supplies sensation to the dorsumof the foot, except the ﬁrst web space. The poster-ior tibial nerve lies in the deep posterior compart- Compartment pressurement, providing sensation of the plantar surface of If the diagnosis is clinically evident, it is not neces- sary to measure the compartment pressures. This should be undertaken only when the clinical signs are unclear, and in patients whose consciousness level is impaired. Measurement by saline injection was ﬁrst done by French and Prince in 1962.14 Both needle techniques3,40 and catheter techni- ques31 require a bubble-free column of saline, and the tip may become blocked by muscle and blood clot. The catheter systems provide a continuous pressure recording for up to 24 h. Moed and Thorderson28 compared the slit cathe- ter, side-ported needle and simple needle techni- ques in a canine model. The values with the simple needle techniques were constantly higher than those with the other techniques. With the side- ported needle, it is not possible to measure con- tinuously. Rorabeck et al.34 and McQueen et al.25 advocate the use of the slit catheter as the most accurate method. Uliasz et al.38 compared the Stry- ker instrument with the IV pump and Whitesides’Figure 1 The four muscle compartments and their method. The latter failed to produce reliableimportant, traversing structures. results, the others gave comparable results.
Acute compartment syndrome of the limb 995 Despite most surgeons’ agreeing that pressure a big difference between individuals, when corre-measurement is the standard method, only about lating absolute pressure levels, clinical signs, nerve50% of the hospitals in the UK and Germany have the function (EMG) and oxygen levels in the muscletechnical equipment to do this, according to inves- tissue.42 At a level of 50 mmHg of intra-compart-tigations of Williams and Sterk.41 It should be men- mental pressure, some healthy volunteers had notioned that it is important to measure all muscle decrease in oxygen saturation in the muscle; otherscompartments in a limb suspected of acute com- showed a decrease to nearly zero. The decrease inpartment syndrome. the muscle response started at 30 mmHg, but at a level of 50 mmHg there was still one volunteer with no measurable muscular response. It is clear thatOther methods the deﬁnition of an absolute critical level of the intra-compartmental pressure is not possible.Willy et al.42 showed the easy and highly accurate Whitesides introduced the concept that the leveluse of transducer tipped probes. They work without of intra-compartmental pressure which causesthe artefacts associated with saline-column sys- ischaemic compromise is related to the perfusiontems. It is also possible to measure the partial pressure.40 This ‘‘delta p’’ pressure, comparable topressure of oxygen in the muscle with catheters, the CPP in brain injury, is the diastolic pressurealthough this method is not routinely used clinically, minus the intra-compartmental pressure. The mostas the critical levels of tissue oxygenations have not commonly cited Dp is less than or equal to 30 mmHg.yet been deﬁned or validated, and its worth has to In studies using Dp, unnecessary fasciotomies werebe proven. Theoretically, it should be helpful to avoided and no signiﬁcant complicationsmeasure the oxygen saturation in the tissue, since occurred.26the pressure is only an indirect measure of tissue The time factor is more critical for the neuraldamage and perfusion. structures than it is for the muscle, but it is impor- Near-infrared spectroscopy can measure the tant to remember that there is a dynamic relation-levels of muscle haemoglobin and myoglobin. The ship between the level of the intra-compartmentalmethod is applied percutaneously, but the limited pressure and the duration of elevated pressure. Themeasurement depth of about 40 mm is a problem, longer the delay to fasciotomy, the worse the out-especially for the deep posterior compartment in come. If the delay is more than 12 h, bad results arethe leg. Most studies with this technique were done inevitable.in chronic compartment syndromes; the value inpatients with an evolving acute compartment syn-drome remains unclear. With further technical Treatmentimprovements, it may offer a rapid, non-invasivetool in the future.16,22 Surgical therapy MRI can show the tissue changes in establishedcompartment syndrome, but fails to identify If compartment syndrome is suspected, all circum-changes in an imminent compartment syndrome ferential dressings should be removed, normal bloodwithout neurological deﬁcit. It is not possible to pressure should be achieved by dealing with anydecide if the swelling and oedema are correlated cause of hypotension. The extremity should not bewith a soft tissue injury itself, or represent signs of elevated, but kept at heart level, in order to main-an evolving compartment syndrome.32 tain perfusion in the compartment. Supplementary Laser Doppler ﬂowmetry and scintigraphy have oxygen, to improve the tissue oxygenation, is help-only been evaluated in chronic compartment syn- ful.dromes. If the Dp is below 30 mmHg, and/or clinical signs are present, fasciotomy of all relevant compart- ments is the treatment of choice and should beCritical pressure performed as an emergency. Prophylactic fasciot- omy is recommended in patients with vascular inju-More important than improving the technical ries, who have had a warm ischaemia time of moredevices is to improve the guidelines for interpreta- than 4—6 h, patients with ligation of the major veinstion of the results and their clinical relevance. in the popliteal region or the distal thigh and The critical level of the absolute intra-compart- patients with crush injuries.mental pressure remains yet undecided. In the lit- In the lower leg, a four-compartment fasciotomyerature, levels ranging from 30 to 50 mmHg are is recommended (Fig. 2). This can be performed byproposed.1,29,31 Experimental studies have shown different techniques: with a single lateral incision,
996 W. Kostler et al. ¨Figure 2 Generous releases are necessary for complete decompression of all four lower leg muscle compartments.with or without ﬁbulectomy or by a double incision anterior and lateral compartments from the lateraltechnique, using medial and lateral incisions.19,30 In side. Its advantage is the possible use of localthe acute situation, the skin incision must be long anaesthesia, even at the bedside; its disadvantageenough to ensure that all underlying muscle is is the need for two separate incisions.decompressed; so-called ‘‘percutaneous’’ fascio- For temporary wound coverage, hypoallogenictomies are dangerous and are not recommended. materials, such as Epigard or Vacuseal, can be used The single incision technique allows adequate (Fig. 3a and b), followed by early deﬁnitive closureexposure of all four compartments;8 ﬁbulectomy using split skin grafting. Recently, in the authors’should be avoided, especially in patients with com- department, since elastic bands have been used toplex tibial fractures. close the wound incrementally, the necessity for The skin incision is made directly over the ﬁbula. skin grafting has decreased and has only been man-A transverse incision is made in the fascia to identify dated in a few cases (Fig. 4).the inter-muscular septum between the anterior In patients with fractures and muscle compart-and lateral compartments and to identify the super- ment syndrome, osteosynthesis is recommended,ﬁcial peroneal nerve. Longitudinal fasciotomies of the technique depending on the fracture localisa-the anterior, the lateral and the superﬁcial dorsal tion, the patient’s status and the quality of the softcompartments are then performed. The ﬁnal step is tissue. If possible, deﬁnitive fracture surgery shouldto divide the origins of the soleus from the ﬁbula and be undertaken at the time of fasciotomy.then, directly behind the ﬁbula, release the deep In the thigh, all three compartments can beposterior compartment. decompressed via a lateral incision. In order to With the double incision technique, the posterior prevent muscle hernia, the authors favour two par-compartments are opened from medially, and the allel incisions in the fascia lata, with an intervening
Acute compartment syndrome of the limb 997 Hyperbaric oxygen In patients with crush injuries, Bouachour et al. showed that adjunctive hyperbaric therapy was associated with signiﬁcantly better wound healing after fasciotomy.5 There are also some experimental data that show better functional results.35 It is our impression, in patients with clinically borderline symptoms, for example, after intra- medullary nailing, that immediate hyperbaric ther- apy in the ﬁrst 2 days often renders fasciotomy unnecessary, but further studies are necessary. Drug therapy Mannitol, as a hyperosmotic diuretic, has been shown to reduce the incidence of compartment syndrome after revascularisation.6 Additionally, free radical scavengers are thought to have bene- ﬁcial effects. In animal studies, the effects are variable and their use in humans is not established.9Figure 3 Before (a) and after (b) provisional tissue cover Summaryusing a synthetic skin substitute. The ﬁnal clinical outcome of an untreated compart- ment syndrome is the replacement of muscle withbridge of at least 4—5 cm. The fracture causing the scar tissue. This produces a severe ﬁbrous contrac-compartment syndrome is ﬁxed deﬁnitively at the ture and a neuropathy of any peripheral nervesame time, provided the patient is physiologically traversing the compartment, leading to serious dys-stable. function. Once this stage is reached, it is never In the forearm, volar and dorsal incisions are possible to restore normal function.necessary. A complete forearm fasciotomy requires For early detection of muscle compartment syn-decompression of each nerve and muscle. When in drome, it is necessary to educate those taking carecombination with fractures, deﬁnitive stabilisation, of patients at risk, especially in the early symptomsusually with plates, is recommended. The implants and signs.should be covered by vital muscle. If the clinical Monitoring of intra-compartmental pressurestatus of the hand remains unclear, the volar incision should be routine in unconscious, sedated and unco-should be extended into the palm and the carpal operative patients. If the Dp remains less thantunnel released. 30 mmHg, in the presence of clinical signs and In patients who develop sepsis, it is important to despite conservative measures, fasciotomy shouldremember that all necrotic tissue has to be excised. be performed as an emergency to preserve theRenal function should be monitored and renal fail- function of the limb.ure prevented. References 1. Allen M, Stirling A, Crawshaw C, Barnes M. Intracompart- mental pressure monitoring of leg injuries. An aid to manage- ment. J Bone Joint Surg 1985;67Br:53—7. 2. Aprahamian T, Gessert G, Banoyk D. MAST-associated com- partment syndrome (MAcompartment syndrome): a review. J Trauma 1989;29:549. 3. Awbrey B, Stenkiewicz P, Mankin H. Chronic exercise induced compartment pressure elevation measured with a miniatured ﬂuid pressure monitor: a laboratory and clinical study. Am J Figure 4 Elastic closure technique. Sports Med 1988;16:610.
998 W. Kostler et al. ¨ 4. Baggot M. Abdominal blow-out: a concept. Anesth Analg 24. Matsen F, Winquist R, Krugmire R. Diagnosis and management 1951;30:295—9. of compartmental syndromes. J Bone Joint Surg 1980;62- 5. Bouachour G, Cronier P, Gouello J, Toulemonde J, Talha A, A:286. Alquier P. Hyperbaric oxygen therapy in the management of 25. McQueen M, Christie J, Court-Brown C. Compartment pres- crush injuries: a randomized double blind placebo-controlled sures after intramedullary nailing of the tibia. J Bone Joint trial. J Trauma 1996;41:333—9. Surg 1990;72B:395—7. 6. Buchbinder D, Karmody A, Leather R, Shah D. Hypertonic 26. McQueen M, Court-Brown C. Compartment monitoring in mannitol: its use in the prevention of revascularisation syn- tibial fractures. The presure threshold for decompressions. drome after acute arterial ischaemia. Arch Surg 1981; J Bone Joint Surg 1996;72BR:99—104. 116:414—21. 27. McQueen M, Gaston P, Court-Brown C. Acute compartment 7. Chase J, Harford F, Pinzur M, Zussman M. Intraoperative lower syndrome: who’s at risk? J Bone Joint Surg 2000;82-B:200—3. extremity compartment pressures. Dis Colon Rectum 2000; 28. Moed B, Thorderson P. Measurement of intracompartmental 43:678—80. pressure: a comparison of the slit catheter, sideported nee- 8. Cooper G. A method of single-incision, four compartment dle, simple needle. J Bone Joint Surg 1993;75A:231—5. fasciotomy of the leg. Eur J Vasc Surg 1992;6:659—61. 29. Mubarak S, Hargens A. Acute compartment syndromes. Surg 9. Dabby D, Greif F, Yaniv M, Rubin M, Dekel S, Leleuk S. Clin North Am 1983;63:539—65. Thromboxane A2 in postischaemic acute compartmental syn- 30. Mubarak S, Owen C. Double-incision fasciotomy of the leg for drome. Arch Surg 1998;133:953—6. decompression in compartment syndromes. J Bone Joint Surg10. Duran W, Takenaka H, Hobson R. Microvascular pathophysiol- 1977;59A:184—7. ogy of skeletal muscle ischaemia-reperfusion. Semin Vasc 31. Mubarak S, Owen C, Hargens A, Garetto L, Akeson W. Acute Surg 1998;11:203—14. compartment syndromes: diagnosis and treatment with the11. Elliott K, Johnstone A. Diagnosing acute compartment syn- aid of the wick catheter. J Bone Joint Surg 1978;60A:1091—5. drome. J Bone Joint Surg 2003;85:625—32. 32. Rominger M, Lukosch C, Bachmann G, Langer C, Schnettler R.12. Fakhouri A, Manoli A. Acute foot compartment syndromes. J Compartment syndrome: value of MR imaging. Radiology Orthop Trauma 1992;6:223—8. 1995;197:296.13. Franc-Law J, Rossignol M, Vernec A, Somogyi D, Shrier J. 33. Rorabeck C. The treatment of compartment syndromes of the Poisoning-induced acute atraumatic compartment syn- leg. J Bone Joint Surg 1984;66-B:93—7. drome. Am J Emerg Med 2000;18:616—21. 34. Rorabeck C, Castle G, Hardie R, Logan J. Compartmental14. French E, Price W. Anterior tibial pain. Br Med J 1962;ii: pressure measurements: an experimental investigation using 1291. the slit catheter. J Trauma 1980;21:446—9.15. Gelbermann R, Garﬁn S, Hergenroeder P, Mubarak S, Menon J. 35. Strauss M, Hargens A, Gershuni D, Greenberg D, Grenshaw A, Compartment syndromes of the forearm: diagnosis and treat- Hart G. Reduction of skeletal muscle necrosis using inter- ment. Clin Orthop 1981;161:252—61. mittent hyperbaric oxygen in a model compartment syn-16. Giannotti G, Cohn S, Brown M, Varela J, McKenney M, Wise- drome. J Bone Joint Surg 1986;68A:1218—24. berg J. Utility of near-infrared spectroscopy in the diagnosis 36. Thomas DD, Wilson RF, Wiencek RG. Vascular injury about the of lower extremity compartment syndrome. J Trauma knee: improved outcome. Am Surg 1989;55:370—7. 2000;48:396—9. 37. Tiwari A, Haq A, Myint F, Hamilton G. Acute compartment17. Heppenstall R, Scott R, Sapega A. A comparative study of the syndromes. Br J Surg 2002;89:397—412. tolerance of skeletal muscle to ischaemia. J Bone Joint Surg 38. Uliasz A, Ishida J, Fleming J, Yamamoto L. Comparing the 1986;68-A:820. methods of measuring compartment pressures in acute com-18. Jepson P. Ischemic contracture, experimental study. Ann Surg partment syndrome. Am J Emerg Med 2003;21:143—5. 1926;84:785. 39. von Volkmann R. Die ischamischen Kontrakturen. Zentralbl ¨19. Kelly R, Whitesides T. Transﬁbular route for fasciotomy of the Chir 1881;8:801. leg. J Bone Joint Surg 1967;49A:1022—3. 40. Whitesides T, Haney T, Morimoto K, Hirada H. Tissue pressure20. Lagerstrom C, Reed R, Rowlands B, Fischer R. Early fasciot- measurements as a determinant for the need of fasciotomy. omy for acute clinically evident post-traumatic compartment Clin Orthop 1975;113:43. syndrome. Am J Surg 1989;158:36—9. 41. Williams P, Russell I, Mintowt-Czyz W. Compartment pressure21. Leach R, Hammond G, Stryker W. Anterior tibial compart- monitoring-current UK orthopeaedic practice. Injury 1998; ment syndrome. Acute and chronic. J Bone Joint Surg 29:229—32. 1967;49A:451—62. 42. Willy C, Sterk J, Voelker H, et al. Das akute Kompartment-22. Mancini D, Bolinger L, Li H, Kendrick K, Chance B, Wilson J. syndrom. Unfallchirurg 2001;104:381—91. Validation of near-infrared spectroscopy in humans. J Appl 43. Zweifach S, Hargens A, Evans K, Smith R, Mubarak S, Akeson Physiol 1994;77:2740—7. W. Skeletal muscle necrosis in pressurized compartments23. Matsen F, Krugmire R. Compartmental syndromes. Surg Gyne- associated with hemorrhagic hypotension. J Trauma 1980; col Obstet 1978;147:943—9. 20:941—7.