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Compartment Syndrome
It refers to the increased pressure in the interstitial tissue with the confined space in our bodies
which leads to poor tissue perfusion and it eventually leads to necrosis of the tissues within that
compartment. Compartment syndrome is an a true orthopedic Emergency
Past Events
The use of explosives in terrorism attacks has led to mass casualty incidents worldwide.
The injuries that result from explosives causes compartment syndrome. The recent examples of
massive incidents include: Tel Aviv (2001), Madrid Subway (2005), Mumbai (2006) and London
subway (2004).
The number of compartment syndrome was rampant in almost all the survivors. They sustained
serious injuries which turned out to be compartment syndrome.
Pathophysiology of compartment syndrome
The classical pathogenesis is as follows: there is increased ICP in interstitial tissues over the
perfusion pressure of capillaries. The accumulation of the necrotic tissues raises ICP within the
closed compartment. The pressure goes to a high level impairing circulation of within the
compartment. Then contents undergo necrosis of varied degrees of necrosis and fibrosis
eventually.
The normal intramuscular resting pressure is normally less than 6mmHg. Resting intramuscular
pressure increases to more than 100mmHg in compartment syndrome. Initially the insult causes
either hemorrhage and edema or both of them in closed fasciae compartments of extremities.
Continued increase in pressure will eventually lead to tamponade of the compartment,
microcirculatory and sustained ischemia.
Triage and identification
After an accident, the triage is done to save life. There are those that need resuscitation, emergent
case, urgent and not urgent. The procedure is to identify compartment syndrome various
depending on the severity and nature of the injuries. Resuscitation is the first step in the field
before transportation to the hospital. You cannot transport victims who are not stable to the
hospital. The primary ai9m of triage is to stabilize the victims to ensure respiratory and
circulation system is fine.
The process of triage can be overpowered by increased number of the victims. A large number of
patients will slow down triage. Increased number of patients will delay the process of
transporting them to hospitals for further management. The response team is likely to be
overwhelmed by large number of the patients.
Signs and symptoms
Compartment syndrome is associated with the 6"Ps“.
1. Pain
2. Pallor
3. Paraesthesia
4. Pulseless
5. Paralysis
6. Poikilothermic
The three first signs of compartment syndrome include: numbness, tingling and paraesthesia.
Complications in delayed treatment
1. Volkmann’s contracture
2. Amputation
3. Weak dorsiflexors
4. Sensory loss
5. Claw toes
6. Rhabdomyolysis
7. Chronic pain
8. Renal failure
Causes of compartment syndrome
There are many causes of compartment syndrome.
1. Increased compartment volume: Fracture, soft tissue injury, iatrogenic and exertion.
2. Decreased compartment volume: Tight splints, lengthy surgeries, comatose patient, prolonged
limb pressure and excessive traction.
Blast injuries
It is another common cause of compartment syndrome. They are divided into four categories:
1. Primary which is caused by wave of blast.
2. Secondary injury is caused by flying debris.
3. Tertiary injury is caused by blast wind.
4. And lastly, quaternary is caused by heat and radiation.
Pre-hospital management
The treatment starts at the scene of the accident or blast. Triage is an important part to stabilize
patients. The goal of managing acute compartment syndrome is restoration of tissue perfusion.
The purpose of pre-hospital management is to stop any respiratory problems and stop any
possible blood loss due to the injury. Stabilize the patient by ensuring patency of the airway
system so that the patient arrives in hospital in normotensive state.
Non- operative management
The patient must be normotensive to prevent further injury of tissues. The casts and
circumferential bandages are removed. Immobilization and fixation should continue in order to
maintain fracture reduction. Raise the limb to the level of the heart. It will reduce arterial inflow
on which perfusion depends. Administer supplemental oxygen.
An indwelling catheter will be used to monitor borderline symptomatic patients. Doubtful
patients should have fasciotomy compared to delay treatment. Fasciotomy is the prophylactic
release of pressure from the compartment before permanent damage takes place.
Operation Management
The gold standard is fasciotomy.
INDICATIONS
1. There must unequivocal and proper clinical findings to warrant fasciotomy
2. The pressure of the closed compartment of about 15-20 mmHg.
3. Continued tissue pressure increase in the compartment.
4. High risk patient, greater than 6 hours of the total limb ischemia
5. Injury which is known for its high risk, for example the blast injuries.
6. Absolute: >30-35mmHg supported by clinical correlation
CONTRA-INDICATIONS
In case of missed compartment syndrome, it should be within (>24-48 hrs.)
Principles of Fasciotomy
a. Diagnosis should be made early
b. Long extensile incision
c. Release total fasciae compartments
d. Preserve all neurovascular structures
e. Debride all necrotic tissues
f. Coverage within 7 to 10 days
References
1. McQueen, M. M., & Gaston, P. (2000). Acute compartment syndrome. Bone & Joint
Journal, 82(2), 200-203.
2. Burch, J. M., Moore, E. E., Moore, F. A., & Franciose, R. (1996). The abdominal
compartment syndrome. Surgical Clinics of North America, 76(4), 833-842.
3. Sheridan, G. W., & Matsen, F. A. (1976). Fasciotomy refers to treatment of acute
compartment syndrome. The Journal of Bone & Joint Surgery, 58(1), 112-115.
4. Fietsam Jr, R., Villalba, M., Glover, J. L., & Clark, K. (1989). Intra-abdominal
compartment syndrome as a complication of ruptured abdominal aortic aneurysm repair.
The american surgeon, 55(6), 396-402.