Compartment syndrome

Acute compartment syndrome is a physiological process where inflammation is trapped inside fascial space. It is seen most frequently seen after traumatic injuries such as crush injuries, femur fractures or full thickness burns but can occur after various non-traumatic injuries. The condition is considered a surgical emergency and any suspicion of acute compartment syndrome should be diagnosed or ruled out quickly.

Non-traumatic compartment syndrome cases are far less frequent but still life-threatening. Examples of non-traumatic causes include injection drug users that miss their shot and inject outside of their veins. Patients with a history of cardiovascular disease or bleeding disorders experiencing internal bleeding into fascial space. Patients with decreased levels of consciousness may also at risk if they may maintain a bizarre position for too long whilst intoxicated/sedated/etc., restricting blood flow to the region.

Chronic compartment syndrome is a lesser, rarer and recurrent version of this effect seen mostly in young athletes. Typically, patients will experience this in the musculature of the distal legs. Often described as a squeezing or tightness type of pain. It is caused when pressure in the muscles increases and puts strain on the fascia. This is seen often in endurance runners or athletes that run excessively for their sport. The inflammation reduces perfusion causing ischemia and pain until they rest for a while, then it should subside.  

For compartment syndrome to appear there must be inflammation, bleeding or some increase of volume in the restricted space of a fascial compartment. Increase of volume inside a closed compartment will cause a pressure increase. The circulatory system regulates this pressure in a homeostatic system. However, when pressure increases too dramatically it cannot maintain perfusion.

In the beginning, veins will be compressed by the pressure but will eventually collapse. They are affected first because their median pressure is lower than arterial pressure. This collapse creates a blockage in venous circulation that causes a decrease in preload and an increase of venous pressure distal to the injury. The decrease in preload reduces arteriovenous pressure in turn. In time, arterial pressure will not be able to overcome the pressure in the fascial space either. At first this will result in tissue ischemia but as the arterial pressure decreases and perfusion decreases, tissue will begin to necrose. If toxins from the necrotic tissue gain access to systemic circulation they may cause rhabdomyolysis, kidney failure and death.

Medical staff should be actively watching for evidence of compartment syndrome in any injury where pressure may build in the fascial space. Symptoms are very similar to those of any other traumatic injury making it easy to miss if you aren’t looking for it.

The trademark symptom of compartment syndrome is pain that is out of proportion to the extent of their injuries. The earliest indication of compartment syndrome is pain while passively stretching. Patients may also report feeling “pins and needles” & weakness in the affected limb, you may notice unusual swelling and pain on palpation. In the later stages, loss of pulse distal to the injury, pallor and weakened or restricted movement.

When compartment syndrome is suspected measurement of the pressure in the fascial space can be done, if the difference between diastolic and compartmental pressure is less than 30 mmHg compartment syndrome should be suspected. Normal compartment pressure is between 0 and 8 mmHg.

Acute compartment syndrome is a medical emergency.

In the pre-hospital setting, patients should be delivered to a hospital with the ability to measure compartmental pressure and ability to perform a fasciotomy if it available. All restrictive clothing or external pressures should be removed; bandages should be removed and/or loosened. Keep the affected limb at the level of the heart to attempt to maintain as much perfusion as possible. Oxygen should be given and an IV installed, analgesics can be given along with saline boluses to increase blood pressure.

In the hospital setting, as mentioned earlier a fasciotomy is typically performed and there is a continuation of the treatment started in the pre-hospital setting.  

Sanders, M. J. (n.d.). Mosby's Paramedic Textbook (Fourth ed.). Louis, MI: Mosby.

Campagne, Danielle. “Ongoing 2b/3a inhibition In Myocardial infarction Evaluation.” Http://Isrctn.org/>, May 2012, doi:10.1186/isrctn06195297.

Echtermeyer, V. & Horst, P. Unfallchirurg (1997) 100: 924. https://doi.org/10.1007/s001130050214

Duncan, C. (n.d.). Decompression Fasciotomy of the lower leg. Retrieved Septembre 13, 2017, from The clinical advisor: http://www.clinicaladvisor.com/anesthesiology/decompression-fasciotomy-of-the-lower-leg/article/581049/

Stracciolini, A. M., & Hammerberg MD, M. E. (2016, May 13). Acute compartment syndrome of the extremities. Retrieved from UpToDate: https://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities?source=search_result&search=compartment+syndrome&selectedTitle=1~150

William P Meehan, I. M. (n.d.). Chronic exertional compartment syndrome . Retrieved September 13, 2017, from UpToDate: https://www.uptodate.com/contents/chronic-exertional-compartment-syndrome?source=search_result&search=chronic+compartment+syndrome&selectedTitle=1~10