Compartment syndrome: Difference between revisions
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==Pathophysiology==
==Pathophysiology==
Cycle: Increased pressure-->impaired perfusion-->disruption of cellular metabolism-->cytolysis with release of osmotically active contents into compartment-->additional fluid drawn into compartment-->increased pressure
*Increased pressure>impaired perfusion>disruption of cellular metabolism>cytolysis with release of osmotically active contents into compartment>additional fluid drawn into compartment>increased pressure


==Presentation==
==Presentation==
#5 Ps: pain, paresthesias, pallor, poikilothermia, pulselessness
*Five Ps:
##NB: pain, paresthesias are NOT reliable
**Pain, paresthesia, pallor, poikilothermia, pulselessness
##Pain at rest or with passive ROM
***Pain, paresthesias are NOT reliable
##Sensory nerves are first to lose conductive ability
*Pain at rest or with passive ROM
*Sensory nerves are first to lose conductive ability


==Etiology==
==Etiology==
#Most often develops soon after significant trauma (particularly involving long bone fractures of the lower leg or forearm)
*Usually develops soon after sig. trauma
#May also occur following minor trauma or from nontraumatic causes:
**(Particularly involving long bone fractures of the lower leg or forearm)
##ischemia-reperfusion injury
*May also occur following minor trauma or from nontraumatic causes:
##coagulopathy
**Ischemia-reperfusion injury
##certain animal envenomations and bites
**Coagulopathy
##extravasation of IV fluids
**Certain animal envenomations and bites
##injection of recreational drugs
**Extravasation of IV fluids
##prolonged limb compression
**Injection of recreational drugs
**Prolonged limb compression


==Diagnosis==
==Diagnosis==
#Non-invasive tests are NOT reliable
*Non-invasive tests are NOT reliable
#Striker
*Stryker
##Normal = 0-8mm Hg
**Normal = 0-8mm Hg
##Capillary blod flow starts to be compromised at 20mmHg
**Capillary blod flow begins to be compromised at 20mmHg
###-Symptoms and signs may develop with pressures above approximately 20  mmHg
**Signs/symptoms may develop with pressures above 20mmHg
##Muscles and nerve fibers at risk at >30-40mmHg
**Muscles and nerve fibers at risk at >30-40mmHg
**Must interpret in light of SBP
***Higher pressures may be necessary with systemic hypertension
****May develop at lower pressures in those with hypotension or peripheral vascular disease
**A single nl compartment pressure reading, early in course of disease, does NOT rule out comp sy.
**Serial measurements important when pt risk is mod to high or clinical suspicion exists


==Specific Syndromes==
===Forearm (<5%)===
*Supracondylar humerus fracture (children)
*Distal radius fractures (adults)


*interpret in light of SBP
*The pressure necessary for injury varies
*Higher pressures may be necessary with systemic hypertension
*May develop at lower pressures in those with hypotension or peripheral vascular disease
*A single normal compartment pressure reading, early in the course of the disease, does NOT rule out comp sy.
*Serial or continuous measurements are important when patient risk is moderate to high or clinical suspicion exists.


==Specific Syndromes==
*Deep volar
===Forearm (<5%)===
**At highest risk for comp sy
(most frequent injuries associated with comp sy in forearm are supracondylar humerus fractures in children and distal radius fractures in adults)
**Contains the digital flexors
***Includes flexor digitorum profundus (responsible for distal interphalangeal joint flexion) and the flexor pollicis longus (responsible for interphalangeal joint flexion of the thumb)  


# deep volar
**Decreased wrist extension
##at highest risk for comp sy
*Superficial volar
##contains the digital flexors
*Dorsal
##decreased wrist extension
**Contains the digital extensors
##includes flexor digitorum profundus (responsible for distal interphalangeal joint flexion) and the flexor pollicis longus (responsible for interphalangeal joint flexion of the thumb)
*Lateral
# superficial volar
# dorsal
##contains the digital extensors
# lateral


===Lower (Leg 2-12% tibia)===
===Lower (Leg 2-12% tibia)===
# Anterior
*Anterior
##most common site compartment sy
**Most common site compartment sy
##contains the four extensor muscles of the foot, the anterior tibial artery, and the deep peroneal nerve
**contains the four extensor muscles of the foot, the anterior tibial artery, and the deep peroneal nerve
##sx include loss of sensation between the 1st and 2nd toes and weakness of foot dorsiflexion
**sx include loss of sensation between the 1st and 2nd toes and weakness of foot dorsiflexion
##late sequelae include foot drop, claw foot, and deep peroneal nerve dysfunction
**late sequelae include foot drop, claw foot, and deep peroneal nerve dysfunction
# Lateral
*Lateral
##contains muscles for foot eversion and some plantar flexion (ie, peroneus brevis, peroneus longus), the peroneal artery, the superficial peroneal nerve, and the proximal portion of the deep peroneal nerve
**contains muscles for foot eversion and some plantar flexion (ie, peroneus brevis, peroneus longus), the peroneal artery, the superficial peroneal nerve, and the proximal portion of the deep peroneal nerve
##sx include deep peroneal nerve deficit (weakness in dorsiflexion and inversion of the foot and sensory loss in the web space between the great toe and the adjacent toe)
**sx include deep peroneal nerve deficit (weakness in dorsiflexion and inversion of the foot and sensory loss in the web space between the great toe and the adjacent toe)
##superficial peroneal nerve also travels through this compartment and supplies sensation to the lower leg and foot
**superficial peroneal nerve also travels through this compartment and supplies sensation to the lower leg and foot
# Deep posterior
*Deep posterior
##muscles that aid in foot plantar flexion, as well as the posterior tibial artery, peroneal artery, and the tibial nerve
**Muscles that aid in foot plantar flexion, as well as the posterior tibial artery, peroneal artery, and the tibial nerve
##sx include plantar hypesthesia, weakness of toe flexion, and pain with passive extension of the toes
**sx include plantar hypesthesia, weakness of toe flexion, and pain with passive extension of the toes
# Superficial posterior
*Superficial posterior
##the major muscles of plantar flexion (ie, gastrocnemius, soleus)
**Major muscles of plantar flexion (ie, gastrocnemius, soleus)
##no major arteries or nerves in this compartment.
**No major arteries or nerves in this compartment.
##least likely to develop ACS in lower leg
**Least likely to develop ACS in lower leg
##sx include pain and a palpably tense and tender compartment
**Sx include pain and a palpably tense and tender compartment


==Treatment==
==Treatment==
#Raise limb to level of heart
*Raise limb to level of heart
#AVOID ice (will further compromise microcirculation)
*AVOID ice (will further compromise microcirculation)
#Bivalve or remove cast if present
*Bivalve or remove cast if present
#Surgery consult
*Surgery consult
#Definitive: Fasciotomy
*Definitive: Fasciotomy
#Goal: < 6hours
**Goal: <6hr


==Source==
==Source==

Revision as of 00:30, 2 April 2011

Pathophysiology

  • Increased pressure>impaired perfusion>disruption of cellular metabolism>cytolysis with release of osmotically active contents into compartment>additional fluid drawn into compartment>increased pressure

Presentation

  • Five Ps:
    • Pain, paresthesia, pallor, poikilothermia, pulselessness
      • Pain, paresthesias are NOT reliable
  • Pain at rest or with passive ROM
  • Sensory nerves are first to lose conductive ability

Etiology

  • Usually develops soon after sig. trauma
    • (Particularly involving long bone fractures of the lower leg or forearm)
  • May also occur following minor trauma or from nontraumatic causes:
    • Ischemia-reperfusion injury
    • Coagulopathy
    • Certain animal envenomations and bites
    • Extravasation of IV fluids
    • Injection of recreational drugs
    • Prolonged limb compression

Diagnosis

  • Non-invasive tests are NOT reliable
  • Stryker
    • Normal = 0-8mm Hg
    • Capillary blod flow begins to be compromised at 20mmHg
    • Signs/symptoms may develop with pressures above 20mmHg
    • Muscles and nerve fibers at risk at >30-40mmHg
    • Must interpret in light of SBP
      • Higher pressures may be necessary with systemic hypertension
        • May develop at lower pressures in those with hypotension or peripheral vascular disease
    • A single nl compartment pressure reading, early in course of disease, does NOT rule out comp sy.
    • Serial measurements important when pt risk is mod to high or clinical suspicion exists

Specific Syndromes

Forearm (<5%)

  • Supracondylar humerus fracture (children)
  • Distal radius fractures (adults)


  • Deep volar
    • At highest risk for comp sy
    • Contains the digital flexors
      • Includes flexor digitorum profundus (responsible for distal interphalangeal joint flexion) and the flexor pollicis longus (responsible for interphalangeal joint flexion of the thumb)
    • Decreased wrist extension
  • Superficial volar
  • Dorsal
    • Contains the digital extensors
  • Lateral

Lower (Leg 2-12% tibia)

  • Anterior
    • Most common site compartment sy
    • contains the four extensor muscles of the foot, the anterior tibial artery, and the deep peroneal nerve
    • sx include loss of sensation between the 1st and 2nd toes and weakness of foot dorsiflexion
    • late sequelae include foot drop, claw foot, and deep peroneal nerve dysfunction
  • Lateral
    • contains muscles for foot eversion and some plantar flexion (ie, peroneus brevis, peroneus longus), the peroneal artery, the superficial peroneal nerve, and the proximal portion of the deep peroneal nerve
    • sx include deep peroneal nerve deficit (weakness in dorsiflexion and inversion of the foot and sensory loss in the web space between the great toe and the adjacent toe)
    • superficial peroneal nerve also travels through this compartment and supplies sensation to the lower leg and foot
  • Deep posterior
    • Muscles that aid in foot plantar flexion, as well as the posterior tibial artery, peroneal artery, and the tibial nerve
    • sx include plantar hypesthesia, weakness of toe flexion, and pain with passive extension of the toes
  • Superficial posterior
    • Major muscles of plantar flexion (ie, gastrocnemius, soleus)
    • No major arteries or nerves in this compartment.
    • Least likely to develop ACS in lower leg
    • Sx include pain and a palpably tense and tender compartment

Treatment

  • Raise limb to level of heart
  • AVOID ice (will further compromise microcirculation)
  • Bivalve or remove cast if present
  • Surgery consult
  • Definitive: Fasciotomy
    • Goal: <6hr

Source

Adapted from KajiQuestions and Donaldson; Perron (ACEP '09)

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