Compartment syndrome is an orthopedic emergency. It is an acute condition of the limbs in which the pressure of isolated or groups of poorly compliant muscle compartments increases dramatically and limits local soft tissue perfusion to the point of motor and sensory impairment and neuronal and tissue ischemic necrosis. Although regional anesthesia is often thought to delay diagnosis and treatment of acute compartment syndrome (ACS), there are only isolated case reports and a lack of evidence-based information to guide the clinical practice. Regardless, practitioners should be aware of the patient risk factors, clinical presentation, and management of this potentially limb-threatening condition. The musculoskeletal structures of the limbs are enclosed within compartments created by investing fascial layers with a limited ability to stretch. These compartments enclose skeletal muscles along with the neurovascular structures that pass through the compartments. If missed, compartment syndrome1 can be a limb- and life-threatening condition.
Compartment syndrome is most common in the lower leg and forearm, although it can also occur in the hand, foot, thigh, and upper arm. In theory, the upper leg muscles are at a lower risk for injury than are the smaller muscles of the lower leg, because the muscles of the thigh can dissipate the large forces of direct trauma, causing less muscle injury and resultant edema.2 Acute compartment syndrome occurs more commonly in one of the four smaller compartments of the lower leg.
The consequences of persistently elevated intracompartmental pressures were first described by Richard von Volkmann,3 who documented nerve injury and late muscle contracture from compartment syndrome after supracondylar fracture of the distal humerus. Jepson4 described ischemic contractures in dog hind legs, resulting from limb hypertension after experimentally induced venous obstruction. Only after about 40 years (since the 1970s) has the importance of measuring compartmental pressures become apparent.
Any condition that can reduce the volume of the compartment or increase the size of the contents of the compartment can lead to an acute compartment syndrome. Examples of factors leading to these changes are presented in Table 50–1.
Table 50–1.Factors leading to compartment syndrome. |Favorite Table|Download (.pdf) Table 50–1. Factors leading to compartment syndrome.
Conditions that Increase the Compartment Volume
Direct soft tissue trauma with or without long bone fracture (10%–20% incidence after closed fracture)
Closed tibial shaft fractures (40%) and closed forearm fractures (12%)
Soft tissue crush injuries without fractures in 23% of cases of compartment syndrome5,6
Open fractures, which should theoretically decompress the adjacent compartments, may lead to compartment syndrome7
Hemorrhage: Vascular injury, coagulopathy
Revascularization of limb after ischemia
High-energy trauma, as from high-speed motor vehicle accident or crush injury
Increased capillary permeability after burns (especially circumferential)
Infusions or high-pressure injections (eg, regional blocks, paint guns)
Extravasations of arthroscopic fluid (eg, after routine ...
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