eMedicine Specialties > Orthopedic Surgery > Trauma

Compartment Syndrome, Lower Extremity: Treatment

Author: Stephen Wallace, MD, Staff, Department of Emergency Medicine, Eastern Idaho Regional Medical Center
Coauthor(s): Stuart Goodman, MD, PhD, FRCSC, FACS, Associate Chairman, Professor, Department of Functional Restoration, Division of Orthopedic Surgery, Stanford University; Head, Division of Orthopedic Surgery, Stanford University Medical Center; Douglas G Smith, MD, Associate Professor, Department of Orthopedic Surgery, University of Washington, Harborview Medical Center
Contributor Information and Disclosures

Updated: Feb 9, 2009

Treatment

Medical Therapy

  • Place the affected limb(s) at the level of the heart. Elevation is contraindicated because it decreases arterial blood flow and narrows the arteriovenous pressure gradient and thus worsens the ischemia.23,24
  • Reduce compartment pressure by releasing 1 side of a plaster cast, which can reduce the pressure by 30%. Bivalving can produce an additional 35% reduction, and cutting Webril (Kendall Healthcare Products Co) may decrease the compartmental pressure by 10-20%.22,25
  • Administer antivenin in cases of snake envenomation; this may reverse a developing compartment syndrome (CS).
  • Correct hypoperfusion with crystalloid solution and blood products.
  • Mannitol may reduce compartment pressures and lessen reperfusion injury.26,27,28
  • Vasodilator drugs or sympathetic blocking drugs appear to be ineffective in the treatment of CS, probably because, in this condition, maximal local vasodilatation is already present.
  • The Undersea and Hyperbaric Medical Society (UHMS) Hyperbaric Oxygen (HBO) Committee reported 13 major syndromes amenable to HBO, of which fourth on the list is crush injury, CS, and other acute traumatic ischemias.29 HBO promotes hyperoxic vasoconstriction, which reduces swelling and edema and improves local blood flow and oxygenation. It also increases tissue oxygen tensions and improves the survival of marginally viable tissue. At the time of surgical debridement, prior treatment with HBO aids in the demarcation of nonviable tissue. The best results are obtained when therapy is started early. Twice-daily treatments at 2.0 atmosphere absolute (ATA) to 2.5 ATA for 90-120 minutes are recommended for 5-7 days, with frequent examinations of the affected area.

Surgical Therapy

The definitive surgical therapy for compartment syndrome (CS) is emergent fasciotomy (compartment release) with subsequent orthopedic reduction or fracture stabilization and vascular repair, if needed. The goal of decompression is restoration of muscle perfusion within 6 hours. Although several surgical techniques have been described, the double-incision fasciotomy of the lower leg is the most common approach. To minimize soft-tissue injury, especially in the setting of fracture/CS, some surgeons prefer a single-incision approach. Regardless of the approach used, adequate exposure of the entire anterior compartment and, in particular, the peroneal nerve is paramount.

Preoperative Details

Partial vascular occlusion may cause a pseudo-CS. Preoperative angiography may be needed to exclude adductor canal compression syndrome and popliteal artery entrapment.

In cases of suspected compartment syndrome (CS), immobilize tibial fractures with the ankle in slight plantar flexion, which decreases the deep posterior compartment pressure and does not lead to an increase in the anterior compartment pressure. (Note: Postoperatively, the ankle is held at 90° to prevent equinus deformity.) Plaster casts should be bivalved, and Webril padding should be split.

Intraoperative Details

Fasciotomy for acute compartment syndrome of the thigh

Have the anesthesiologist administer an anti-staphylococcal antibiotic (eg, cefazolin or a broad-spectrum cephalosporin). Prepare and drape the thigh in standard surgical fashion. Make a lateral incision beginning just distal to the intertrochanteric line and extending to the lateral epicondyle. Use subcutaneous dissection to expose the iliotibial band, and then make a straight incision through the iliotibial band in line with its fibers.30,31,32,33,34

Carefully reflect the vastus lateralis off the lateral intermuscular septum, making sure to coagulate all perforating vessels as they are encountered. Make a 1- to 2-cm incision in the lateral intermuscular septum, and, using Metzenbaum scissors, extend the septum proximally and distally along the length of the incision.

After the anterior and posterior compartments have been released, measure the pressure of the medial compartment. If the pressure is elevated, make a separate medial incision to release the adductor compartment. Before closing, ensure that meticulous hemostasis has been obtained.

Pack the wound open and apply a large, bulky dressing. In 1-3 days, the patient is returned to the operating suite, at which time any additional necrotic muscle is debrided. This process may be required several times. If possible, the skin is loosely approximated during the final operation.

Fasciotomy for CS of the lower leg

Single- and double-incision techniques have been described. The double-incision technique is safer and more effective and should be used in general.35,33,34

The image below depicts a single-incision fasciotomy.

(Click Image to enlarge.) Single-incision fasciot...

(Click Image to enlarge.) Single-incision fasciotomy. Photographs courtesy of DG Smith, MD, Harborview Hospital, Seattle, WA.

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(Click Image to enlarge.) Single-incision fasciot...

(Click Image to enlarge.) Single-incision fasciotomy. Photographs courtesy of DG Smith, MD, Harborview Hospital, Seattle, WA.


The images below depict anterolateral and posteromedial fasciotomies.

(Click Image to enlarge.) Two-incision anterolate...

(Click Image to enlarge.) Two-incision anterolateral fasciotomy. Photographs courtesy of DG Smith, MD, Harborview Hospital, Seattle, WA.

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(Click Image to enlarge.) Two-incision anterolate...

(Click Image to enlarge.) Two-incision anterolateral fasciotomy. Photographs courtesy of DG Smith, MD, Harborview Hospital, Seattle, WA.


(Click Image to enlarge.) Two-incision posteromed...

(Click Image to enlarge.) Two-incision posteromedial fasciotomy. Photographs courtesy of DG Smith, MD, Department of Orthopedics, Harborview Hospital, Seattle, WA.

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(Click Image to enlarge.) Two-incision posteromed...

(Click Image to enlarge.) Two-incision posteromedial fasciotomy. Photographs courtesy of DG Smith, MD, Department of Orthopedics, Harborview Hospital, Seattle, WA.


Double-incision fasciotomy

  • The anterior and lateral compartments are approached through 1 incision.
  • Make an approximately 15-cm incision over the anterior intermuscular septum, centered halfway between the fibular shaft and the crest of the tibia. The incision must be large enough to provide adequate visualization. In an elective decompression, a 4- to 5-cm incision may be adequate.
  • Use subcutaneous dissection for wide exposure of the fascial compartments.
  • Make a transverse incision to expose the lateral intermuscular septum and to identify the superficial peroneal nerve just deep to the septum.
  • Make a small nick in the anterior intermuscular septum midway between the septum and tibial crest.
  • Using Metzenbaum scissors or a fasciotome, release the anterior compartment proximally (aim for the patella) and distally (aim for the center of the ankle) in line with the tibialis anterior.
  • Then, perform a longitudinal fasciotomy of the lateral compartment in line with the fibular shaft. Direct the scissors toward the lateral malleolus to stay posterior to the superficial peroneal nerve.
  • Make a second longitudinal incision 2 cm posterior to the posterior medial margin of the tibia.
  • Use wide subcutaneous dissection to allow identification of the fascial planes.
  • Retract the saphenous vein and nerve anteriorly. Make a transverse incision to identify the septum between the deep and superficial posterior compartments. Release the fascia over the superficial posterior compartment. Release the fascia over the gastrocsoleus complex along the length of the compartment.
  • Make another fascial incision over the FDL muscle and release the entire deep posterior compartment.
  • As the surgical dissection is carried proximally, note the origin of the soleus from the proximal third of the tibia. Detach the soleal bridge, and retract to expose the FDL and tibialis posterior.
  • After release of the posterior compartment, identify the tibialis posterior muscle compartment.36 If increased tension is evident in this compartment, release it over the extent of the muscle body.
  • Antibiotic beads may be used if a comminuted open fracture is present, particularly if bone loss occurs. Vessiloops or rubber bands may be used on the skin to prevent excessive skin retraction. Pack the wound open and apply a posterior plaster splint with the ankle held at 90°. Return the patient to the operating room for debridement in 1-3 days if necessary or for skin closure.

Postoperative Details

Monitor the patient's hemodynamic status and maintain adequate blood pressure and volume status. If rhabdomyolysis occurs, continue hydration, monitor urine output and kidney function, and watch potassium status closely.

Daily redress wounds that are left open, and undertake subsequent operative debridements as needed. Prophylactic antibiotics may be of benefit.

Follow-up

  • The postoperative wound check is at 3-5 days.
  • Suture removal occurs at 10-14 days (if the wounds are closed).
  • Patients may need skin grafting or traction dermoplasty if the skin defect is large.
  • The rehabilitation protocol depends most on the underlying mechanism of injury. For stable tibial shaft fractures treated with closed reduction and casting, the following guidelines apply:
    • 0-3 Weeks
      • Begin quadriceps sets, hamstring sets, gluteal sets, and straight-leg raises before hospital discharge.
      • Early weightbearing is performed as tolerated.
      • Ice, elevation, and anti-inflammatory drugs are recommended.
    • 3-5 Weeks
      • Increase weightbearing.
      • Begin range-of-motion (ROM) exercises on knee (0-140°) and start open-chain exercises with Thera-Band (The Hygienic Corporation, Akron, Ohio) or ankle weights.
      • Begin closed-chain exercises if patient is bearing weight.
    • 6-8 Weeks
      • Ambulate, bearing full weight.
      • Continue open- and closed-chain exercises.
    • 3-4 Months
      • Discontinue cast or patellar tendon bearing (PTB).
      • Begin ankle stretching, ROM exercises, and strengthening.

Complications

Postoperative motor deficits resulting from compartment syndrome (CS) are treated initially with appropriate orthotic devices (eg, a footdrop brace when the anterior compartment of the leg is affected). If function does not return in about 1 year, tendon transfer and other forms of reconstructive surgery may be considered. Volkmann contracture is the residual limb deformity that continues over weeks to months following untreated acute CS or ischemia from persistent arterial insufficiency. Approximately 1-10% of all cases of CS develop Volkmann contracture.22

Infection is a serious complication of CS. In a retrospective review by Matsen et al, 11 of 24 extremities that had late surgical decompression developed infections.37 Five (almost one half) of these infections led to an amputation.

Hypesthesia and painful dysesthesia can also result from CS. These may resolve slowly with time. Diphenylhydantoin or phenytoin (Dilantin; Pfizer Inc, New York, NY), gabapentin (Neurontin; Pfizer Inc), and carbamazepine (Tegretol; Novartis, East Hanover, NJ) may be of some value in making the patient more comfortable.

Recurrent CS has occurred in athletes and is thought to be related to severe scarring and the subsequent closing of the initial compartment release.

Systemic complications include acute renal failure, sepsis, and acute respiratory distress syndrome (ARDS). Most fatalities are due to prolonged intensive care admissions with sepsis and multisystem organ failure.

More on Compartment Syndrome, Lower Extremity

Overview: Compartment Syndrome, Lower Extremity
Workup: Compartment Syndrome, Lower Extremity
Treatment: Compartment Syndrome, Lower Extremity
Follow-up: Compartment Syndrome, Lower Extremity
Multimedia: Compartment Syndrome, Lower Extremity
References
Further Reading
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Keywords

compartment syndrome, CS, chronic CS, chronic exertional CS, exertional CS, recurrent CS, subacute CS, Volkmann ischemia, chronic exertional compartment syndrome, exertional rhabdomyolysis, recurrent compartment syndrome, subacute compartment syndrome, fasciotomy, compartment release

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Contributor Information and Disclosures

Author

Stephen Wallace, MD, Staff, Department of Emergency Medicine, Eastern Idaho Regional Medical Center
Stephen Wallace, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Stuart Goodman, MD, PhD, FRCSC, FACS, Associate Chairman, Professor, Department of Functional Restoration, Division of Orthopedic Surgery, Stanford University; Head, Division of Orthopedic Surgery, Stanford University Medical Center
Stuart Goodman, MD, PhD, FRCSC, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, California Medical Association, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Douglas G Smith, MD, Associate Professor, Department of Orthopedic Surgery, University of Washington, Harborview Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Steven I Rabin, MD, Clinical Associate Professor, Loyola University Medical Center; Chair, Department of Orthopedic Surgery, Dreyer Medical Clinic
Steven I Rabin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Fracture Association, AO Foundation, and Orthopaedic Trauma Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center
Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS, Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center
Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

 
 
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