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COMPARTMENT SYNDROME

Overview

  • Limb-threatening condition with increased pressure within an enclosed space, resulting in tissue ischaemia

  • Untreated compartment syndrome leads to tissue necrosis, permanent functional impairment and if severe, renal failure and death

  • Causes:

    • Increased compartment volume​

      • Fractures/dislocations​

      • Ischaemia-reperfusion injury

      • Severe soft tissue injury

      • Haemorrhage into compartment

      • Strenous muscle use (exercise, seizures, tetany

      • Significant oedema

    • Reduced compartment volume​

      • Burns eschar causing constriction​

      • Tight dressings/casts

      • Prolonged limb positioning (eg during surgery)

Overview

Pathophysiology

  • Excess fluid or significant construction increases pressure

  • Venous collapse occurs first, leading to transudation of fluid into already constricted compartment, in accordance with the Starling equation

    • Leads to limb congestion and accelerating compartment pressure buildup

    • When venous presure is higher than capillary perfusion pressure, capillaries collapse

  • Perfusion pressure is elevated as a physiologic response, causing reduced tissue perfusion

  • Hypoxia cuses tissues to undergo anaerobic metabolism

    • Lactic acid accumulates​

    • Cell membranes are unable to maintain osmolar gradient as ATP-dependent Na+/K+ pump fails

    • Lipid peroxidation of the cell membrane stimulates inflammatory cascade, activating neutrophils and generating hypoxanthine

  • Reperfusion of an ischaemic compartment brings an abundant supply of oxygen than reacts with hypoxanthine to produce superoxide​

    • Iron in red blood cells react with​ hydrogen peroxide to form hydroxyl radical and other free radicals that are highly toxic

    • Platelet aggregation and microvascular clotting is also promoted by these radicals causing further ischaemia

Pathophysiology

Clinical assessment

  • High index of suspicion when there is disproportionate pain in an extremity after injury at rest of with passive stretch

  • Classic features (The six Ps)

    • Pain​

    • Pallor

    • Poikilothermia (Perishingly cold)

    • Pressure

    • Paralysis/paraesthesia (sensory nerves affected first, then motor nerves)

    • Pulselessness (very late sign!)

Clinical assessment

Investigations

  • Less helpful in diagnosis of compartment syndrome

  • Usually only helpful in suspicious non-communicative patients (eg heavily sedated in ICU)

  • Bloods:

    • Elevated K+ and creatinine​

    • Elevated creatine kinase

    • Presence of urine myoglobin

  • Imaging:​

    • Plain radiographs (for fractures)​

    • Doppler ultrasound to evaluate arterial flow and presence of deep venous thrombosis

  • Compartment pressure measurement​

    • Normal intracompartmental pressure (ICP) is <10 mm Hg​

    • Decompression recommended when difference of ICP and diastolic blood pressure (Δp > 30 mm Hg)

    • Commercial direct pressure measurement equipment

    • Can otherwise be performed using wide-bore needle attached to CVP monitor​

    • Both techniques require experience and know-how, and should not be performed unless confident due to risk of catastrophic missed compartment syndrome

Investigations

Management

  • Early intervention is critical

    • Irreversible tissue injury and muscle necrosis may start as early as 3 hours after onset of compartment syndrome​

  • Fasciotomy principles

    • Complete opening of all tight fascial envelopes​​

    • Limited fracture fragment exposure (in fracture cases)

Management

Postoperative care

  • Supportive care

    • May require monitoring in critical care unit​

    • Analgesia

    • Wet-to-dry dressings

  • Wound closure​

    • Usually through delayed primary closure or skin grafts

    • Delayed at least 48 hours​

    • Can be performed provided underlying muscle healthy

    • If muscle non-viable, debridement to healthy bleeding muscle is required to provide healthy wound bed for skin grafts

  • Treatment of rhabdomyolysis​

    • Maintain urine output at 1-2 ml/kg/hr​

    • Mannitol

Postoperative care

Complications

  • Volkmann's ischaemic contracture

    • Myonecrosis and secondary contracture after prolonged muscle iscahemia​

    • First step of management of known contractures is occupational therapy

  • Limb loss​

  • Permanent nerve damage

  • Renal failure

  • Death

  • Scarring from fasciotomies and skin grafts

Complications
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