Compartment

Syndrome

The Sneaky Emergency

Maegan Vaz

October 8, 2017

Case Study

• 36 yr old male

• Obese

• POD 1 s/p L

mandibulectomy, L neck

dissection with R fibula

reconstruction

• 10 hour long supine position

• Intubated in PACU overnight

(12 hours)

• PCA for pain

• Complaints

• Extreme R buttock pain –

exquisitely tender to

touch

• Erythema localized to

right buttock

• Swollen R buttock

What is compartment

syndrome?

A condition in which

increased compartment

pressure within a

confined space,

compromises the

circulation and viability

of the tissues within that

space

https://syndromespedia.com/wp-content/uploads/2012/06/Anterior-Compartment-Syndrome.jpg

First Documentation

The first medical reference

was in 1881, when German

doctor Richard von

Volkmann described a

permanent contracture of

the forearm related to

ischemia within muscle

compartments of the arm

https://en.wikipedia.org/wiki/Volkmann%27s_contracture

Anatomy Review

• Compartments –

grouping of muscles,

nerves and blood

vessels in the

extremities

• Inelastic fascia encases

the compartments,

protects the tissues, and

maintains tissue shape

Colton, C. (2012). Compartment Syndrome. [Digital Image]

Retrieved from : https://www2.aofoundation.org

Lower Extremity

Compartments - Calf

Figure 1. Cross-section Medial Calf. Adapted from “Grey’s Anatomy,”

2009. Retrieved from : https://radiopaedia.org/images/24012

• Anterior

• MOST likely to be affected

• Tibialis anterior, extensor muscles of toes, anterior tibial artery, and deep peroneal nerve

• Lateral

• Peroneus longus and peroneus brevis, superficial peroneal artery

• Deep Posterior

• Tibialis posterior, flexor digitorum longus, and flexor hallus longus

•Superficial Posterior• Gastrocnemius and soleus muscle.

Sural nerve• Lithotomy positions

Calf Cross - Section

Von Keudall, Arvind G et al. (September, 2015). Diagnosis and Treatment of

Acute Extremity Compartment Syndrome. The Lancet, Volume 386, Issue 100000,

pg 1299-1320. dio: http://dx.doi.org/10.1016/S0140-6736(15) 00277-9

Lower Extremity

Compartments – Thigh • Anterior

• Vastus lateralis, vastus intermedius, srtorius, and recutus femoris

• Femoral nerve/artery

• Medial

• Pectineus, external obturator, gracilis muscles

• Adductors

• Obturator nerve

• Posterior

• Semimembranous, semitendinosis, and biceps femoris

• Sciatic nerve Figure 2. Cross-section Medial Calf. Adapted from

“Grey’s Anatomy,” 2009. Retrieved from :

https://radiopaedia.org/images/24012

Thigh Cross – Section

Von Keudall, Arvind G et al. (September, 2015). Diagnosis and Treatment of

Acute Extremity Compartment Syndrome. The Lancet, Volume 386, Issue 100000,

pg 1299-1320. dio: http://dx.doi.org/10.1016/S0140-6736(15) 00277-9

Physical Assessment

• Lower Extremity - Calf

• Deep Peroneal Nerve (most commonly affected) - anterior compartment.

• Sensory territory is confined to webspace between 1st and 2nd toes and activates dorsiflexion

• Superficial Peroneal Nerve runs along lateral compartment and supplies dorsum of the foot (except 1st webspace)

• Posterior Tibial Nerve is within deep posterior compartment and provides sensation to plantar surface of the foot – motor function is flexion of the toes

McKnight, J. & Adcock, B. (December 1997). Paresthesias: A Diagnostic

Approach. American Family Physician. Volume 56, Issue 9, pg 2253-2260.

Physical Assessment

• Lower Extremity - Thigh

• Femoral Nerve

• Anterior Compartment

• Most commonly affected

• Obturator Nerve

• Medial Compartment of

thigh

• Sciatic Nerve

• Posterior Compartment of

thigh

McKnight, J. & Adcock, B. (December 1997). Paresthesias: A Diagnostic

Approach. American Family Physician. Volume 56, Issue 9, pg 2253-2260.

Physical Assessment

•Upper Extremity

•Radial Nerve

• Back of the arm and

wraps around to skin of

forearms and hands

•Median Nerve

•Main nerves of arm

that runs full length

•Axilla injury

•Ulnar Nerve

•Extends from cervical

collar

•4th and 5th digits

McKnight, J. & Adcock, B. (December 1997). Paresthesias: A Diagnostic

Approach. American Family Physician. Volume 56, Issue 9, pg 2253-2260.

Pathophysiology

/

Muscle Perfusion Pressure =

Diastolic Blood Pressure - Intra-Muscular

Pressure

Two General Principles :

DECREASED space within compartment

INCREASE within compartment contentColton, C. (2012). Compartment Syndrome. [Digital Image]

Retrieved from : https://www2.aofoundation.org

Venous Outflow Obstruction

Pathophysiology

Decreased Arterial Perfusion

Multiple pathways leading to final

common pathway: cellular anoxia

death of the muscle within compartment.

Compartment Pressure

Increased Capillary

Permeability

Increased Intracompartmental

Pressure

ISCHEMIA

Causes of ACS

• Bone fracture (trauma or intentional) ~70%

• Crush Injury

• Hemorrhage (anticoagulation, intramuscular injury)

• Less common causes… r/t fluid retention –rhabdomyolysis, muscle hypertrophy, DVT

• Tight casts/splints/circumferential dressings/tourniquet

• Burns

• Injection injury/Extravasation

• Intra-osseous infusions

• Infection

• Surgical positioning

Any event (external or internal) that increases the

pressure within a compartment by decreasing the

capacity or increasing the volume

Clinical Presentation

Pain

6 P’s

Pallor

Pressure

Paresthesia Paralysis

Pulselessness

PAIN

• Pain that is out of proportion

to the injury

• Pain with passive stretch of

muscle

• Persistent deep ache or

burning

FIRST presenting symptom

PRESSURE

• Often not utilized – proper equipment required

and user errors are common

• >30-40 mmHg considered diagnostic

PARESTHESIA

• A condition in which you feel sensation of numbness or prickling

• Pins & Needles

• Early contained to one compartment

• Late globally within limb

PALLOR

• Rarely present

• Often times, redness

progresses to pallor

• Sign of vascular

injury and quickly

leads to ischemia

• LATE stage –

emergent

intervention require

PULSELESSNESS

• The existence of distal

pulses DO NOT exclude

compartment syndrome

• Check above and below

area of concern

• Late stage – indicates

progression

https://upload.wikimedia.org/wikipedia/commons/thumb/

d/d1/Pulse_sites-en.svg/220px-Pulse_sites-en.svg.png

PARALYSIS

• Complete loss of muscle function for one or more

muscle groups

• Very late finding indicating nerve damage

http://drawingbooks.org/lutz1/source/images/000088.png

Who is at risk?

Increased

Muscle Mass

Bone Fracture (2/3 of

patients)

Tibia/radius most

commonly seen

Trauma

Cast/Splint on

broken bone

OR - same

position for >

8 hrs

Lithotomy

Men in their

30’s

Diagnosis

Difficult to DEFINATIVELY diagnose early on

Late stage:

• Hyperkalemia from

muscle breakdown

• Acute renal failure or

myoglobinuria

Early Stage:

• Extreme, unrelenting

pain

• Elevated

intracompartmental

pressure

Diagnosis

Stryker Manometer is most commonly used

• Normal at rest 0 - 10 mmHg

• Pressures > 30-40mmHg require surgical decompression, combined with supporting clinical picture

https://www.slideshare.net/drrohitvikas/compartment-syndrome-14077010

Support Your Case

• What are the precipitating factors?

• Is this a high risk patient?

• Imaging

• MRI/CT scan can show swelling of the gluteal muscles

• Can use measure the pressure within the compartment?• Is it >30 – 40

mmHg?

• Additional helpful objective information • Elevated creatinine

phosphokinase (CPK) indicates muscle damage or ischemia

Treatment

• Surgical

decompression with a

fasciotomy is the

definitive treatment

• 8 hour ischemia time

can cause irreversible

damage to muscles

Nucleus Medical Media Inc / Alamy Stock Photo

Case Study – Review the Facts

• Age – young males at high risk

• Obese – muscular patients are often at higher risk,

but could weight and gravity play a factor?

• Time – OR for 10 hours, supine and intubated for at

least another 12 hours – unable to communicate

pain.

• Pain – Very tender. Exquisitely tender to touch. Is

there pain when flexing the hip?

Case Study #2

• 26 y/o athletic male with no prior medical history

• Playing soccer on day prior to admission was kicked in R thigh sustaining a hairline femur fracture

• Admitted for observation

• Ambulated w/pain into urgent care

• Denied numbness/tingling

• Labs on admission :

CPK 971 (22-198) K 5WBC 12.8 H&H 12.5/35.5 PLTs 213

Compartment pressure 45mmHg.

Fasciotomy

Incision prior

to fasciotomy

Fasciotomy in progress –

muscle is still beefy red

and viable

Prognosis

• Overall complication rate is about 50-60% if

treatment is delayed >12

• About 50% lower limbs require amputation when

treatment is delayed, 92% will develop neuropathy

• Mortality is related to renal failure or sepsis

Things to Remember

• Don’t dismiss pain – look

into the reason for the pain

• Don’t over medicate

• Perform a COMPLETE

exam

• Don’t elevate – need to

maintain perfusion

• TRUST YOUR GUT

References

Colton, C. (2012). Compartment Syndrome. [Digital Image] Retrieved from : https://www2.aofoundation.org

Donaldson, J., Haddad, B., & Khan, W. (June 27, 2014). The Pathophysiology, Diagnosis and Current Management of Acute

Compartment Syndrome. The Open Orthapaedics Journal. Volume 8, pg 185-193. doi: 10.2174/187432500140801085

Kam, J.L., Hu, M., Peiler, L.L., & Yamamoto, L.G. (July, 2003). Acute Compartment Syndrome Signs and Symptoms Described in

Medical Textbooks. Hawaii Medical Journal. Retrieved from http://evols.library.manoa.hawaii.edu/bitstream/10524/53621/1/2003-

07p142-144.pdf

Kostler, W., Strohm, P.C., & Sudkamp, N.P. (August, 2005) Acute Compartment Syndrome of the Limb. Injury. Volume 36 Issue 8,

pg 992-998. Retrieved from http://doi.org/10.1016/j.injury.2005.01.007

McKnight, J. & Adcock, B. (December 1997). Paresthesias: A Diagnostic Approach. American Family Physician. Volume 56, Issue

9, pg 2253-2260.

Stracciolini, A., & Hammerberg, M. (May 13, 2016). Acute Compartment Syndrome of the Extremities. UpToDate. Retrieved

from https://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities

Ulmer, Todd. (September 2002). The Clinica Diagnosis of Compartment Syndrome of the Lower Leg: Are Clinical Findings

Predictive of the Disorder? Journal of Orthopaedic Trauma. Volume 16, Issue 7 & pp 572-577. Retrieved from

http://journals.lww.com/jorthotrauma/Abstract/2002/09000/The_Clinical_Diagnosis_of_Compartment_Syndrome_of.6.aspx

Von Keudall, Arvind G et al. (September, 2015). Diagnosis and Treatment of Acute Extremity Compartment Syndrome. The Lancet,

Volume 386, Issue 100000, pg 1299-1320. dio: http://dx.doi.org/10.1016/S0140-6736(15) 00277-9