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Compartment Syndrome

 - 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
                   - references: 
                          - Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome.
                          - Diagnostic techniques in acute compartment syndrome of the leg.

 - 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 - loss of motor function
          - note that in teenagers, the muscle is stronger and more durable than adults, and so there may be a delayed appearance of loss
                   of active motors;
    - 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;
          - or 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); 
    - ref: Physicians’ Ability to Manually Detect Isolated Elevations in Leg Intracompartmental Pressure

- Compartment Pressure Monitoring: 
      - Ankle and knee position as a factor modifying intracompartmental pressure in the human leg.

  - reperfusion injury 
         - need to address:
                - fluid loss
                - shock
                - acidosis
                - hyperkalemia
                - myoglobinuria
                - renal failure
         - consider:
                - perioperative hydration
                - mannitol
                - bicarbonate 

 Scientific Papers: Fasciotomy after trauma to the extremities.

Recurrent Compartment Syndrome Leading to the Diagnosis of McArdle Disease: Case Report

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

Quantification of intracompartmental pressure and volume under plaster casts.

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.

Well-limb compartment syndrome after prolonged lateral decubitus positioning. A report of two cases.

Compartment Syndrome in Upper Limb