COMPARTMENT SYNDROME

The limbs contain muscles along with vessels and nerves that are enclosed by Fascia, bones and interosseous membrane. This osteo-fascial compartment is very resistant to expansion. And whenever there is swelling of muscles due toany reason, the compartment doesn’t expand, and there is increase in pressure, leading to hampering of Micro-Circulation.

Compartment syndrome is an elevation of the interstitial pressure in a closed osteo-fascial compartment that results in microcirculation compromise.

The end result is ischemic muscle necrosis and nerve damage. This leads to PERMANENT fibrosis and contractures and varying degrees of nerve injury.

Compartment syndrome can develop anywhere where skeletal muscle is surrounded by fascia, suchas in buttock, thigh, shoulder, hand, foot, arm, and lumbar paraspinal muscles.

But the most commonly involved areas are the anterior and deep posterior compartments of the leg and the volar compartment of the forearm.

Compartment syndrome can be classified as • Acute or• Chronic,

ACUTE compartment syndrome is caused by an acute injury and can cause devastating complications. It is an ORTHOPEDIC EMERGENCY. It is usually is caused by• fractures, especially

Tibial fracturesForearm fracturesSupracondylar humeral fractures

• Crush injuries• Severe soft tissue trauma, • arterial injury, • limb compression during altered consciousness,• and burns.

PATHOLOGYInjury causes edema that results in increased tissue pressure, decreased capillary blood flow, (pulses and oxygen saturation is usually normal). This causes local oxygen deprivation leading to tissue necrosis. This leads to permanent nerve damage and muscle contractures. Experimental evidence suggests that “even 30 mm Hg increase in intracompartmental pressure can lead to significant muscle necrosis in 8 hours even with normal blood flow.”

Higher pressures have been shown to cause greater compromise of neuromuscular viability in shorter periods of time.

Diagnosis:Diagnosis is CLINICAL and is based on a high degree of suspicion especially in the under risk groups (forearm fractures, tibia fractures, supracondylar fractures, crush injuries etc.)

Signs and symptoms of acute compartment syndrome include :• PAIN, out of proportion to the injury and not relieved by usual doses of

analgesics,• Muscle weakness, hyperasthesia, paraesthesias.• Remember, CS is problem of MICROCIRCULATION, pulses and sO2 are usually

normal• SWELLING (increase in limb girth).• TIGHTNESS of the involved compartment, • STRETCH TEST: pain with passive motion of the muscles passing through the

compartment,

The diagnosis of acute compartment syndrome may be delayed in patients with multiple injuries or altered consciousness and in children.

Compartment pressure measurements are used ONLY IF an adequate examination cannot be performed. Monitoring of compartment pressures is helpful in patients with altered neurological function, continuous epidural anesthesia, peripheral nerve injury, or tourniquet palsy. ETC

.

Studies have shown, however, that pressure measurements are erroneous in as many as 30% of patients and should not be used as the primary determinant for or against fasciotomy.

If compartmental syndrome is diagnosed, immediate fasciotomy is indicated. Compartment syndrome associated with a fracture should be treated at the time of fracture stabilization.Nonreamed intramedullary nailing is preferred for lower limbs.

In impending compartment syndrome we can try to lower the compartment pressure by• Splitting any cast and underlying padding if done.• Splitting any circular constrictive bandages • RICE therapy (Rest, immobilisation, cold compresses, elevation)

If symptoms do not resolve within 30 to 60 minutes after appropriate treatment, or IF IN DOUBT, DO A FASCIOTOMY.

Even with timely fasciotomy, many patients have long-term sequelae, including altered sensation, swelling, pain, functional deficits, and cosmetic concerns.

CHRONIC COMPARTMENT SYNDROME

Chronic exertional compartment syndrome is defined as reversible ischemia secondary to a noncompliant osteofascial compartment that is unresponsive to the expansion of muscle volume that occurs with exercise. It most often in the anterior or deep posterior compartment of the leg. Exertional compartment syndrome of the lower extremity is most common in long-distance runners and military recruits pushed past normal limits of functional tolerance.It also has been reported to occur elsewhere, including the forearms in weightlifters, rowers, welders, and others who place large demands on their upper extremities. Anabolic steroid and creatine use also increases muscle volume.

Exercise can increase muscle volume by 20%, causing an increase in pressure in a noncompliant compartment. CECS is most common in young adult recreational runners, elite athletes, and military recruits.

The importance of an accurate history cannot be overemphasized in the evaluation of patients with lower extremity pain.A typical patient with CECS is a competitive runner, 20 to 30 years old, who describes exercise-induced pain and a feeling of tightness that begins after 20 to 30 minutes of running or exercise. The pain usually resolves within 15 to 30 minutes of cessation of exercise. Paresthesias of the nerves running through the involved compartment often are reported. Physical examination may reveal tenderness over the musculature of the involved compartment,

Symptoms are bilateral in about 75% of patients. Studies have indicated that a 2-year delay in diagnosis is typical.

Treatment includes: • Conservative measures include relative rest (limiting

activity to a level that avoids all but minimal symptoms)• Antiinflammatory medications, • manual stretching and strengthening of the involved

muscles, • and orthotics.

If symptoms persist, if pressures are extremely elevated, or if the athlete desires to continue activity at the same level, fasciotomy of the involved compartments is indicatedSubcutaneous and endoscopic techniques have been described for fasciotomy.

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