- Discussion:
-
pathophysiology:
- compartment syndrome is elevation of interstitial pressure in closed fascial compartment that results in microvascular compromise;
- as duration & magnitude of interstitial pressure increase, myoneural function is impaired & necrosis of soft tissues eventually develops;
-
intracompartmental pressure:
- necrosis of tissue may begin at interstitial pressure as low as 30 mm
- while others have suggested that it begins at higher level;
- w/ periods of hypotension and trauma to limb, interstitial tissue pressure of 30 mm of mercury has been suggested as
threshold at which diagnosis of compartment syndrome should be considered;
-
diastolic pressure: (Whiteside' Theory):
- development of a compartment syndrome depends not only on intra-compartment pressure but also depends on systemic blood pressure;
- DBP - CP should be greater than 30
- ref:
Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome.
- Common Sites of Involvement:
-
compartment syndrome of the upper extremity:
-
compartment syndrome of forearm:
-
compartment syndrome of hand and wrist (after crush, hemmorhage, edema);
-
compartment syndrome of the lower extremity:
-
compartment syndrome of thigh
- compartment syndrome of the leg:
-
compartment syndrome from tibial frx
-
chronic compartment syndromes
-
fasciotomy of leg
- anatomy: (4 compartments)
-
lateral compartment
-
superfical posterior compartment
-
deep posterior compartment
-
anterior compartment
-
foot compartment syndromes
- Exam:
- blood pressure (compartment syndrome is potentiated by hypotension);
- extreme pain out of proportion to the injury,
- pain on passive ROM of the fingers or toes (stretch pain of the involved compartment):
- patient will usually hold injured part in a position of flexion to maximally relax the fascia and reduce pain;
- pallor of the extremity,
- paralysis,
- paresthesias (early loss of vibratory sensation);
- pulses:
- when checking an extremity pulse (such as dorsalis pedis) be sure to occlude the other major artery (posterior tibial artery) so that retrograde flow does
not confuse the diagnosis;
- alternatively, apply a pulse oximetry monitor to the great toe, and sequentially occlude the posterior tibial and dorsalis pedis pulses;
- compare pulses to the opposite non injured side (to rule out
vascular injury);
- Compartment Pressure Monitoring:
Complications:
-
reperfusion injury
- references:
-
Mechanisms of Disease: The Role Of Reperfusion-Induced Injury In The Pathogenesis Of The Crush Syndrome.
- need to address:
- fluid loss
- shock
- acidosis
-
hyperkalemia
- myoglobinuria
-
renal failure
- consider:
- perioperative hydration
-
mannitol
-
bicarbonate
Scientific Papers: Fasciotomy After *Trauma* to the Extremities.
Pelvic and Lower Extremity Trauma--Symposium: Compartment Syndromes of the Lower Leg.
Hyperbaric oxygen reduces edema and necrosis of skeletal muscle in compartment syndromes associated with hemorrhagic hypotension.
A comparative study of the tolerance of skeletal muscle to ischemia. Tourniquet application compared with acute compartment syndrome.
Compartmental syndrome complicating Salter-Harris type II distal radius fracture.
The changes in intramuscular pressure and femoral vein flow with continuous passive motion, pneumatic compressive stockings, and leg manipulations.
Simulation of compartment syndrome by rupture of the deep femoral artery from blunt trauma.
Ankle and knee position as a factor modifying intracompartmental pressure in the human leg.
Quantitation of skeletal-muscle necrosis in a model compartment syndrome.
Quantification of intracompartmental pressure and volume under plaster casts.
Compartment syndrome as a complication of the Hauser procedure.
Intramuscular pressures with limb compression clarification of the pathogenesis of the drug-induced muscle-compartment syndrome.
A practical approach to compartmental syndromes. Part II. Diagnosis.
Skeletal muscle necrosis in pressurized compartments associated with hemorrhagic hypotension.
Acute Compartment Syndrome: Update on Diagnosis and Treatment. T.E. Whitesides Jr. MD and M.M. Heckman MD. J Am Acad Orthop Surg. 1996; 4: 209-218.
Well-Limb Compartment Syndrome After Prolonged Lateral Decubitus Positioning.
