Compartmen

t Syndrome
The Sneaky Emergency

Maegan Vaz
October 8,
2017
 Case Study
• 36 yr old male

• Obese
• Complaints
• POD 1 s/p L • Extreme R buttock pain –
mandibulectomy, L neck
dissection with R fibula exquisitely tender to
reconstruction touch
• Erythema localized to
• 10 hour long supine
position right buttock
• Swollen R buttock
• Intubated in PACU overnight
(12 hours)

• PCA for pain

 What is compartment
syndrome?

A condition in which
increased
compartment
pressure within a
confined space,
compromises the
circulation and viability
of the tissues within that
space

https://syndromespedia.com/wp-content/uploads/2012/06/Anterior-Compartment-Syndrome.jpg
 First
Documentation
The first medical reference
was in 1881, when German
doctor Richard von
Volkmann described a
permanent contracture of
the forearm related to
ischemia within muscle
compartments of the arm

https://en.wikipedia.org/wiki/Volkmann
%27s_contracture
 Anatomy Review
• Compartments –
grouping of muscles,
nerves and blood
vessels in the
extremities

• Inelastic fascia encases

the compartments,
protects the tissues, and
maintains tissue shape

Colton, C. (2012). Compartment Syndrome. [Digital Image]

Retrieved from : https://www2.aofoundation.org
 Lower Extremity
Compartments - Calf
• Anterior
• MOST likely to be affected
• Tibialis anterior, extensor
muscles of toes, anterior
tibial artery, and deep
peroneal nerve

• Lateral
• Peroneus longus and
peroneus brevis, superficial
peroneal artery

• Deep Posterior
• Tibialis posterior, flexor
digitorum longus, and flexor
hallus longus

•Super
Sural nerve Figure 1. Cross-section Medial Calf. Adapted from “Grey’s Anatomy,”
ficial• Lithotomy positions 2009. Retrieved from : https://radiopaedia.org/images/24012

Poste
rior
Calf Cross - Section

Von Keudall, Arvind G et al. (September, 2015). Diagnosis and Treatment of

Acute Extremity Compartment Syndrome. The Lancet, Volume 386, Issue 100000,
pg 1299-1320. dio: http://dx.doi.org/10.1016/S0140-6736(15) 00277-9
 Lower Extremity
Compartments –
• Anterior
Thigh
• Vastus lateralis, vastus
intermedius, srtorius,
and recutus femoris
• Femoral nerve/artery

• Medial
• Pectineus, external
obturator, gracilis
muscles
• Adductors
• Obturator nerve

• Posterior
• Semimembranous,
semitendinosis, and
biceps femoris
• Sciatic nerve Figure 2. Cross-section Medial Calf. Adapted from
“Grey’s Anatomy,” 2009. Retrieved from :
https://radiopaedia.org/images/24012
Thigh Cross – Section

Von Keudall, Arvind G et al. (September, 2015). Diagnosis and Treatment of

Acute Extremity Compartment Syndrome. The Lancet, Volume 386, Issue 100000,

pg 1299-1320. dio: http://dx.doi.org/10.1016/S0140-6736(15) 00277-9

 Physical Assessment
• Lower Extremity - Calf
• Deep Peroneal Nerve (most
commonly affected) - anterior
compartment.
• Sensory territory is confined to
webspace between 1st and 2nd toes
and activates dorsiflexion

• Superficial Peroneal Nerve runs

along lateral compartment and
supplies dorsum of the foot (except
1st webspace)

• Posterior Tibial Nerve is within

deep posterior compartment and
provides sensation to plantar surface
of the foot – motor function is
flexion of the toes
McKnight, J. & Adcock, B. (December 1997). Paresthesias: A Diagnostic
Approach. American Family Physician. Volume 56, Issue 9, pg 2253-2260.
 Physical Assessment
• Lower Extremity - Thigh
• Femoral Nerve
• Anterior Compartment
• Most commonly affected
• Obturator Nerve
• Medial Compartment of
thigh
• Sciatic Nerve
• Posterior Compartment of
thigh

McKnight, J. & Adcock, B. (December 1997). Paresthesias: A Diagnostic

Approach. American Family Physician. Volume 56, Issue 9, pg 2253-2260.
 Physical Assessment
•Upper Extremity
•Radial Nerve
• Back of the arm and
wraps around to skin of
forearms and hands
•Median Nerve
• Main nerves of arm
that runs full length
• Axilla injury
•Ulnar Nerve
• Extends from cervical
collar
• 4th and 5th digits

McKnight, J. & Adcock, B. (December 1997). Paresthesias: A Diagnostic

Approach. American Family Physician. Volume 56, Issue 9, pg 2253-2260.
 Pathophysiology
Muscle Perfusion Pressure =

Diastolic Blood Pressure - Intra-

Muscular
Pressure

Two General Principles :

DECREASED space within compartment

INCREASE within compartment content

Colton, C. (2012). Compartment Syndrome. [Digital Image]

Retrieved from : https://www2.aofoundation.org /

 Pathophysiology
Compartment Pressure

Venous Outflow Obstruction

Increased Capillary
Permeability

Increased Intracompartmental
Pressure
Decreased Arterial
Perfusion

Multiple pathways leading to final

ISCHEMIA
death of thepathway:
common muscle within compartment.
cellular anoxia

 Causes of ACS
Any event (external or internal) that increases the
pressure within a compartment by decreasing the
capacity or increasing the volume
• Bone fracture (trauma or • Tight
intentional) ~70%
casts/splints/circumferential
• Crush Injury dressings/tourniquet
• Burns
• Hemorrhage
(anticoagulation, • Injection
injury/Extravasatio
intramuscular n
injury)
• Intra-osseous
• Less common causes… r/t infusions
fluid retention –
rhabdomyolysis, muscle • Infection
hypertrophy, DVT • Surgical positioning
 Clinical Presentation
6
P’s
Pain Pallor

Pressure Pulselessness

Paresthesia Paralysi
s
 PAI
N
• Pain that is out of proportion
to the injury

• Pain with passive stretch of

muscle

• Persistent deep ache or

burning

FIRST presenting symptom

 PRESSURE
• Often not utilized – proper equipment required
and user errors are common
• >30-40 mmHg considered diagnostic
PARESTHESI
A
• A condition in which you
feel sensation of numbness
or prickling

• Pins & Needles

• Early contained to one

compartment
• Late globally within
limb
 PALLO
R
• Rarely present
• Often times, redness
progresses to pallor
• Sign of vascular
injury and quickly
leads to ischemia
• LATE stage –
emergent
intervention
require
PULSELESSNESS

• The existence of distal

pulses DO NOT exclude
compartment syndrome
• Check above and below
area of concern
• Late stage – indicates
progression

https://upload.wikimedia.org/wikipedia/commons/thumb/
d/d1/Pulse_sites-en.svg/220px-Pulse_sites-en.svg.png
 PARALY SI
•
S
Complete loss of muscle function for one or more
muscle groups
• Very late finding indicating nerve damage

http://drawingbooks.org/lutz1/source/images/000088.png
 Who is at
risk?
Bone Fracture (2/3 of Cast/Splint on
patients) broken bone
Tibia/radius most
commonly seen OR - same
Trauma position for >
8 hrs
Lithotomy

Increased Men in their

Muscle Mass 30’s
 Diagnosis
Difficult to DEFINATIVELY diagnose early
on
Early Stage: Late stage:

• Extreme, unrelenting • Hyperkalemia from

pain muscle breakdown

• Elevated • Acute renal failure or

intracompartmenta myoglobinuria
l pressure
 Diagnosis

Stryker Manometer is
most commonly
used
• Normal at rest
0 - 10 mmHg
• Pressures > 30-
40mmHg require
surgical
decompression,
combined with
https://www.slideshare.net/drrohitvikas/compartment-syndrome-14077010
supporting
clinical picture
 Support Your
Case • Can use measure the
• What are the
pressure within the
precipitating compartment?
factors? • Is it >30 – 40
mmHg?
• Is this a high risk
patient? • Additional helpful
objective information
• Imaging • Elevated
• MRI/CT scan can creatinine
show swelling of phosphokinase
the gluteal
muscles (CPK)
 Treatmen
t
• Surgical
decompression with a
fasciotomy is the
definitive treatment
• 8 hour ischemia time
can cause
irreversible damage
to muscles
Nucleus Medical Media Inc / Alamy Stock Photo
Case Study – Review the Facts

• Age – young males at high risk

• Obese – muscular patients are often at higher risk,

but could weight and gravity play a factor?
• Time – OR for 10 hours, supine and intubated for at
least another 12 hours – unable to communicate
pain.
• Pain – Very tender. Exquisitely tender to touch. Is
there pain when flexing the hip?
 Case Study #2
• 26 y/o athletic male with no prior medical history

• Playing soccer on day prior to admission was kicked

in R thigh sustaining a hairline femur fracture
• Admitted for observation
• Ambulated w/pain into urgent care
• Denied numbness/tingling
• Labs on admission :
CPK 971 (22-198) K 5
WBC 12.8 H&H 12.5/35.5 PLTs 213

Compartment pressure 45mmHg.

 Fasciotomy
Incision prior
to
fasciotomy

Fasciotomy in progress –
muscle is still beefy red
and viable
 Prognosis

• Overall complication rate is about 50-60% if

treatment is delayed >12
• About 50% lower limbs require amputation when
treatment is delayed, 92% will develop neuropathy
• Mortality is related to renal failure or sepsis
 Things to
Remember
• Don’t dismiss pain – look
into the reason for the pain
• Don’t over medicate

• Perform a COMPLETE
exam
• Don’t elevate – need to
maintain perfusion
• TRUST YOUR GUT
 Reference
s
Colton, C. (2012). Compartment Syndrome. [Digital Image] Retrieved from : https://www2.aofoundation.org

Donaldson, J., Haddad, B., & Khan, W. (June 27, 2014). The Pathophysiology, Diagnosis and Current Management of Acute
Compartment Syndrome. The Open Orthapaedics Journal. Volume 8, pg 185-193. doi: 10.2174/187432500140801085

Kam, J.L., Hu, M., Peiler, L.L., & Yamamoto, L.G. (July, 2003). Acute Compartment Syndrome Signs and Symptoms Described in
Medical Textbooks. Hawaii Medical Journal. Retrieved from http://evols.library.manoa.hawaii.edu/bitstream/10524/53621/1/2003-
07p142-144.pdf

Kostler, W., Strohm, P.C., & Sudkamp, N.P. (August, 2005) Acute Compartment Syndrome of the Limb. Injury. Volume 36 Issue 8,
pg 992-998. Retrieved from http://doi.org/10.1016/j.injury.2005.01.007

McKnight, J. & Adcock, B. (December 1997). Paresthesias: A Diagnostic Approach. American Family Physician. Volume 56, Issue
9, pg 2253-2260.

Stracciolini, A., & Hammerberg, M. (May 13, 2016). Acute Compartment Syndrome of the Extremities. UpToDate. Retrieved
from https://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities

Ulmer, Todd. (September 2002). The Clinica Diagnosis of Compartment Syndrome of the Lower Leg: Are Clinical Findings
Predictive of the Disorder? Journal of Orthopaedic Trauma. Volume 16, Issue 7 & pp 572-577. Retrieved from
http://journals.lww.com/jorthotrauma/Abstract/2002/09000/The_Clinical_Diagnosis_of_Compartment_Syndrome_of.6.aspx

Von Keudall, Arvind G et al. (September, 2015). Diagnosis and Treatment of Acute Extremity Compartment Syndrome. The
Lancet,
Volume 386, Issue 100000, pg 1299-1320. dio: http://dx.doi.org/10.1016/S0140-6736(15) 00277-9