Compartment syndrome

SPONSORED ADVERTISEMENT

ANAESTHETIC PRACTICE MANAGEMENT

Designed for Anaesthetists by Anaesthetist

Nova streamlines your anaesthetic practice with expert management, billing and financial services – so you can focus on what truly matters.

Learn More
View Notes

{}

Compartment Syndrome

General

  • Fascial membranes in the human body surround muscle groups.
  • Compartment syndrome (CS): Increased pressure in fascial compartments compromises circulation and function of tissue within these compartments.
    • Positive feedback: ischemia → necrosis → edema → further increase in compartment pressure.
  • Epidemiology:
    • Most commonly occurs after trauma, especially long bone fractures.
    • Incidence: 7.3/100k in men and 0.7/100k in women.
    • Common sites: fibular and extensor compartments in the lower leg, extensor compartment in the forearm.

Definition

  • CS is a condition where increased pressure within a closed compartment compromises the circulation and function of tissues within that space.
  • Acute limb CS: Acutely raised pressures in an osseofascial compartment of a limb, most commonly seen in the calf or forearm, occasionally in the upper arm, thigh, buttock, foot, or hand.
  • Other clinically relevant compartments include the cranium, eye, spinal column, abdomen, chest, and pericardium.

Aetiology

  • Commonest cause: Trauma, usually after a fracture, in male patients less than 35 years old.Pasted image 20240905184933.png

View or edit this diagram in Whimsical.

Pathophysiology

  • Muscles, nerves, and blood vessels lie within fascial compartments.
  • After direct injury, ischaemia–reperfusion, or fluid extravasation, the pressure within these compartments may rise, reducing perfusion and leading to local ischaemia of muscles and nerves.
  • Ischaemia results in tissue membrane damage and fluid leakage, increasing tissue pressure.
  • Raised tissue pressure causes venous outflow obstruction and increased venular pressure.
  • Increased capillary pressure induces a cycle of fluid transudation, swelling, and rising intracompartmental pressure.
  • If intracompartmental pressure approaches capillary pressure, microcirculatory perfusion ceases, leading to tissue infarction unless pressure is relieved.
  • Reperfusion can continue tissue damage initiated in the ischaemic phase.
  • Without relief within a few hours, irreversible changes occur with muscle necrosis, contracture, and nerve and vessel damage.
  • Irreversible injury in the leg may occur as early as 4 hours after injury onset.

Risk Factors

Pasted image 20240905184949.png

View or edit this diagram in Whimsical.

Prevention

  • Limb ischaemia prevention by restricting elevated leg time in lithotomy position, or tourniquet release.
  • Lower legs from lithotomy and deflate tourniquet intermittently (every 2–3 hours).
  • Careful patient positioning and avoidance of perioperative hypotension can reduce CS risk.

Diagnosis

ACS Definition

  • Elevated pressure within a compartment leads to impaired circulation and tissue function.

Diagnostic Indicators

  1. Pain with passive stretch
  2. Pain out of proportion
  3. Increasing analgesic requirement
  4. Tenderness/firmness
  5. Sensory loss
  6. Motor weakness

Pressure Measurements

  • Absolute Pressure (P)
  • Delta Pressure (ΔP): ΔP = Diastolic Pressure (DP) – Compartment Pressure (CP)
  • Severe pain over the affected compartment, often disproportionate to the apparent injury, is the cardinal symptom of a CS.
  • Aggravated by passive stretching of involved muscles.
  • Paraesthesia, especially loss of two-point discrimination in the nerves traversing the compartment, is characteristic.
  • 3 P’s (low sensitivity, high specificity):
    • Pain – main clinical sign, classically “out of proportion” to injury
    • Paresthesia – late clinical sign
    • Paresis – even later clinical sign

Diagnosis

  1. Clinical signs/symptoms (3 P’s)
  2. Measure compartment pressure, where normal compartment pressure ~8 mmHg
  3. Calculate Critical Δ Tissue pressure = Diastolic BP – compartment pressure
    • more than 30 mmHg = normal
    • <30 mmHg = indication for fasciotomy (100% sensitivity and specificity)

Common Causes for Diagnostic Confusion

  • Extremes of age
  • Acute confusional state
  • Spinal cord injury
  • Multiple injuries
  • Drug or alcohol overdose
  • Sedation/analgesia
  • Recovery from general anaesthesia
  • Regional anaesthesia
  • Analgesia (e.g., PCA)

Pressure Monitoring

  • Diagnosis is usually clinical, though compartmental pressure monitoring is recommended for high-risk patients.
  • Normal muscle compartment pressure (absolute): >10–12 mmHg.
  • Diagnosis and fasciotomy are required if compartmental perfusion pressure (delta) <30 mmHg.

Treatment

  • Urgent Treatment: Surgical decompression is the mainstay of therapy.
  • Goals: Decrease tissue pressure, restore blood flow, minimize tissue damage and functional loss.
  • Keep the limb at heart level; avoid elevation to prevent critical perfusion decrease.
  • Monitor for systemic effects of massive rhabdomyolysis: hyperkalemia, myoglobinuria, acute renal failure, and systemic inflammatory response syndrome with cardiovascular and respiratory failure.
  • Achieve adequate pain control with the lowest possible dose to avoid delayed CS diagnosis.
  • Sudden pain increase should be considered CS until proven otherwise.
  • Avoid epidurals in high-risk patients to prevent delayed CS diagnosis; if used, employ low-concentration solutions.
  • Peripheral regional anesthesia is safe and does not delay CS diagnosis; use dilute concentrations and minimal adequate dose.
  • Liberal indication for fasciotomy.

Links

References:

  1. Farrow, C., Bodenham, A., & Troxler, M. (2011). Acute limb compartment syndromes. Continuing Education in Anaesthesia Critical Care &Amp; Pain, 11(1), 24-28. https://doi.org/10.1093/bjaceaccp/mkq041

Summaries:

Copyright
© 2025 Francois Uys. All Rights Reserved.

id: “52395ba8-890e-48c8-884e-403865bb903e”

The Brain (all notes)

Please log in to view your notes.

Related article

Load More