Acute Compartment Syndrome
|Video: Acute compartment syndrome|
Overview The muscle groups of the human limbs are divided into section or compartments. Acute compartment syndrome (ACS) occurs when increased pressure within a compartment compromises circulation and function of tissues within that area. common sites of ACS is the leg and forearm.
Acute compartment syndrome: A critical pressure increase within a confined compartmental space causing a decline in the perfusion pressure to the tissue within that compartment. Usually a result of trauma (bone fracture)
Chronic (Exertional) compartment syndrome: most commonly occurs in young adult recreational runners, elite athletes, and military recruits. It is caused by increased intracompartmental pressure within a fascial space; however, the mechanism of why pain occurs is unknown.
Rhabdomylosis: Medical condition involving the rapid dissolution of damaged or injured skeletal muscle. This disruption of skeletal muscle integrity leads to release of intracellular muscle components, including myoglobin, creatine kinase, lactate dehydrogenase, as well as electrolytes, into the bloodstream.
Peripheral Vascular Disease: An atherosclerotic process that causes stenosis and occlusion of non-cerebral and non-coronary arteries. For example plaque in the lower limbs leading to claudication.
See Aetiology below
Signs and Symptoms
Clinical Presentation Pain is the most important symptom. Pain out of proportion to apparent injury (early and common finding). The pain is described as a persistent deep ache or burning pain. Paresthesia can occur (onset within approximately 30 minutes to two hours of ACS)
Clinical examination 6P’s: Pain is the most important and can be aggravated on passive stretch of affected compartment (as shown above). Patient with a pulse does not exclude ACS. Pallor is not common because there is still circulation to the area. Pressure, on palpation ACS is often described to be wood like, there can be tenderness. Parasthesia is common and paralysis is a late finding.
|Remember It is IMPORTANT to maintain a high index of suspicion among patients at risk for acute compartment syndrome. The most important determinant of poor outcome from ACS is a delayed or missed diagnosis|
Diagnosis ACS is diagnosed on the basis of history and clinical findings no need for laboratory studies. Investigations that could be performed include FBC, creatinine kinase (CK) levels and urine analysis which in typically show myoglobinuria. Elevated CK and myoglobinuria is a sign of muscle damage. Further investigation that can help in diagnosis is the measurement of compartment pressure, which can be done with a handheld manometer.
- Trauma Fractures – account for 75% of cases of ACS
- Trauma without fractures – thermal burns, crush injuries, penetrating injuries, prolonged limb contraction
- Non-traumatic causes (less common) – ischemia reperfusion injury, thrombosis, bleeding disorders and vascular disease, recreational drugs, nephrotic syndrome.
Management Immediate surgical consultation – fasciotomy or not to fasciotomy (conservative therapy). Immediate management of suspected ACS includes relieving all external pressure on the compartment. The limb should be level with the heart (not elevated). Further management include giving analgesia, oxygen, fluids. Surgeons will decide wether to perform a fasciotomy and if the limb is not viable amputation may be necessary.
Complications and Prognosis
|Remember Early diagnosis and appropriate treatment is IMPORTANT as patient have better outcome|
- Muscle contracture
- Sensory deficit
- Fracture nonunion
- Limp amputation
- Coexisting Rhabdomyolysis -> renal failure
Mortality rate for patients requiring fasciotomy may reach as high as 15%. Morbidity following fasciotomy may include muscle weakness and nerve injury