eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Compartment Syndrome
Updated: Mar 11, 2009
Introduction
Background
In 1881, Richard von Volkmann reported the effects of ischemia on the soft-tissue components of a limb compartment. The contractures that developed were named after him. Wilson first described the initial case of exertional compartment syndrome in 1912. Mavor, in 1956, first reported a case of chronic compartment syndrome. Since then, various cases of compartment syndrome have been reported in the literature, and pathophysiology and treatment options have been discussed. The incidence of compartment syndrome varies depending on the patient population studied and the etiology of the syndrome. In a group of patients with leg pain, according to Qvarfordt and colleagues, 14% of them were noted to have anterior compartment syndrome.1 Compartment syndrome was seen in 1-9% of leg fractures.
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Pathophysiology
Compartment syndrome results primarily from increased intracompartmental pressure. The mechanism involved in the development of increased pressure depends on the precipitating event. Two distinct types of compartment syndrome have been recognized. The first type is associated with trauma to the affected compartment, as seen in fractures or muscle injuries contained in a compartment of the limb. The second form, called exertional compartment syndrome, is associated with repetitive loading or microtrauma related to physical activity.2,3,4,5,6,7,8,9 Thus, compartment syndrome may be acute or chronic in nature.
Various theories have been proposed to explain the increase in compartment pressure.10 One commonly accepted theory is that the inflammatory response associated with trauma results in vascular permeability and vasodilatation that drives fluid out of the intravascular channels into the interstitial compartment. The presence of plasma proteins attracts more fluid into the compartment. Lactic acid has been shown to be in high concentration in the leg muscles of patients with exercise-induced pain.
The increase in compartment pressure has deleterious effects on the soft-tissue contents of the compartment. The increased tissue pressure results in decreased blood flow that, in turn, causes ischemia. Compartment pressures of 50 mm Hg have been associated with blood flow that has been decreased to 70%. At 80 mm Hg, the pressure has been reduced to 5%. Other studies have shown that compartment pressures return to normal after a fasciotomy.11
How long can soft tissues tolerate the increased compartmental pressure? Whitesides and colleagues noted that muscle necrosis was seen when compartment pressures of 50 mm Hg were left for 4-8 hours. Compartment pressures of 40 mm Hg left for 6 hours were associated with early neuromuscular deficits, according to Sheridan and coauthors. According to Gelberman and colleagues, tissue pressures of more than 50 mm Hg applied to the median nerve for 4 hours resulted in sensorimotor abnormalities.
Clinical
History
The clinical presentation of patients with compartment syndrome is typically pain that appears out of proportion to the injury. In severe trauma, such as an open fracture, it is difficult to differentiate pain from the fracture from pain resulting from increased compartment pressure. In exertional compartment syndrome, pain is associated with prolonged or repetitive exercise and is relieved by rest.
Physical
- Common symptoms observed in compartment syndrome include a feeling of tightness and swelling. The 5 Ps (ie, pain, pallor, paresthesias, paralysis, pulselessness) are pathognomonic of compartment syndrome; however, these usually are late signs. Extensive and irreversible injuries to the soft tissues may have taken place by then.
- Peripheral pulses and capillary refill remain normal in most cases of acute compartment syndrome. The pain may be associated with paresthesia involving the superficial sensory nerve in that compartment.
- The acute syndrome most commonly involves the forearm and leg. With the chronic syndrome, the anterior pretibial compartment in the leg is most often involved. Gluteal and thigh involvement is uncommon.12
- Measurement of compartment pressures still remains the standard for diagnosis of compartment syndrome. Various methods, as well as equipment, can be used for this purpose. A transducer connected to a catheter usually is introduced into the compartment to be measured. This is the most accurate method of measuring compartment pressure and diagnosing compartment syndrome. Measurement of the compartment pressure then can be performed at rest, as well as during and after exercise.
- With the acute syndrome, the exact pressure threshold is controversial, but typical ranges are from 30-45 mm Hg at rest. Some sources state that it is better to associate this pressure to diastolic pressure (that is, within 10-30 mm Hg of diastolic pressure).
- With chronic compartment syndrome, resting intracompartmental pressure above 15 mm Hg or exertional pressure greater than 30 mm Hg generally is considered to be elevated. A prolonged elevated pressure of more than 20 mm Hg for 5 minutes or more after completion of exercise also is considered to be abnormal.
- In a 2009 study, Arato et al measured intracompartmental pressure and tissular oxygenation to determine the progression of compartment syndrome in patients who had undergone revascularization surgery for lower limb ischemia.13 The investigators used near-infrared spectroscopy to evaluate whether postsurgery oxygenation was low, an indication of insufficient secondary microcirculation. According to the study, the derived pressure and oxygenation measurements aided in determining whether patients required conservative or surgical treatment for compartment syndrome.
- The first deficits may be subclinical, with a decrease in vibratory sensation to a 256 cycle per second tuning fork.
- A soft-tissue mass may be noticed as a result of herniation of fat and/or muscle tissue from the fascial defect that is often found in the lower third of the leg.
Causes
Trauma, fractures, bleeding in an enclosed space, external compression of the limb, vigorous exercise, small thrombotic or embolic events, and intramuscular injection have all been implicated in the pathogenesis of compartment syndrome.
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| References |
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References
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Further Reading
Keywords
compartment syndrome, fasciotomy, anterior compartment syndrome, compartmental syndrome, acute compartment syndrome, exertional compartment syndrome, compartment pressure, intracompartmental pressure
