View source for Compartment syndrome

==Background==
*Most commonly caused by tibia fracture (anterior compartment) 

{{Compartment Syndrome Indications}}

===Pathophysiology===
*Tissue perfusion is difference between diastolic BP and compartment pressure 
**As compartment pressure increases, tissue perfusion decreases

===Etiologies===
*Orthopedic 
**[[Tibial fracture]] 
**[[Forearm fracture]]
*Vascular 
**Ischemic-reperfusion injury 
**Hemorrhage
***Can be spontaneous in anticoagulated patients
*Iatrogenic 
**Vascular puncture in anticoagulated patients 
**IV/intra-arterial drug injection 
**Constrictive casts 
*Soft tissue injury 
**Prolonged limb compression 
**[[Crush injury]] 
**[[Burn]]
**[[Snake bite]]
**Expanding hematoma

==Clinical Features==
===General Symptoms===
*Compartment is swollen, firm, tender with squeezing 
*Usually develops soon after significant trauma 
**May be delayed up to 48hr after the event 

====5 P's====
*Classic signs of disruption in arterial flow, not of compartment syndrome 
**Only found once arterial flow has stopped (very late finding)

#Pain (early finding)
#*Severe, out of proportion to physical findings 
#*Worse with passive stretch of distal body part such as toes or fingers (muscle extension > increased volume > increased pressure) 
#*Often the presenting symptom.
#Paresthesia (early finding)
#*Occurs in sensory distribution of affected nerve 
#Pallor
#Paralysis: late finding
#Pulselessness: late finding

===Lower Leg Specific Syndromes===
*Anterior 
**Nerve: deep fibular (peroneal): sensation of 1st webspace 
**Muscle: tibialis anterior: foot/ankle dorsiflexion 
*Lateral 
**Nerve: superficial fibular (peroneal) nerve: sensation of lateral aspect of lower leg, dorsum of foot 
**Muscle: peroneus longus and brevis: foot plantarflexion 
*Deep posterior 
**Nerve: posterior tibial nerve: sensation of plantar aspect of foot 
**Muscle: tibialis posterior/flexor hallucis longus/flexor digitorum longus: Pain with passive extension of the toes 
*Superficial posterior 
**Nerve: sural cutaneous nerve: sensation of lateral aspect of foot 
**Muscle: gastrocnemius/soleus/plantaris: weakness of plantar flexion
[[File:lower_leg_compartment.png|thumb|Lower Leg Compartment]]

===Hand===
*Crush injury, with or with out associated fracture 
*Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles 
*Diagnosis 
**Clinical, not based on actual compartment pressure 
**Pain 
***Deep, constant, poorly localized, out of proportion to exam 
**"Intrinsic minus" position at rest 
***MCP joint extended with proximal IP joint slightly flexed 
**Pain with passive stretch of involved compartmental muscles 
***Interosseus: performed with MCP joint extended and PIP jionts fully flexed 
***Thenar, hypothenar: performed by extension of MCP joint 
**Tense swelling of affected compartment

===Forearm===
[[File:Forearm_compartments.jpg|thumb|forearm compartments]]
*Associated with supracondylar fracture (peds), distal radius fracture (adults) 
*Compartments 
**Dorsal (highest risk) 
**Volar

===Foot===
[[File:Compartments of the Foot.png|thumb|Compartments of the foot]]
*Number of compartments is controversial, but at least 4, up to 9 
**Medial, lateral, central, interosseous, adductor
**Mechanism - crush injuries
**Other mechanisms - foot surgery, Lisfranc fracture, cast immobilization, prolonged extremity positioning, snake bites, severe ankle sprains with arterial disruption<ref>Haddad, Steven L. Managing risk: Compartment syndromes of the foot. AAOS, 2007. http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp</ref>
**5-17% of calcaneus fractures result in compartment syndrome
**Diagnosis
***Pain out of proprtion
***Pain worse with passive dorsiflexion (stretching intrinsic musculature of foot); concurrent metatarsal fracture cloud this finding
***Do not rely on absent pulse or complete anesthesia, which are late findings
***Measure absolute compartment pressures in [http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp insertion sites found here]
**Treatment
***Elevate extremity to level of heart (above the heart, and there will be reduction of O2 perfusion)
***SCDs may help decrease interstitial pressure, improve venous return/arterial flow
***Fasciotomy within 24 hrs of injury if pressures > 30 mmHg

===Lumbar Paraspinal===
*Compartment enclosed on the lateral, dorsal and ventral aspects by thoracolumbar fascia and medial aspect by spinous processes and interspinous ligaments
*Mechanisms
**Direct trauma
**Atraumatic mechanism (Heavy weight lifting) 
***Typically males in their 20's and 30's
**Recent surgery causing compromised blood supply
*Characteristics
**Pain of the low back refractory to analgesia
**Radiation of pain to the groin
**Tender and tense lumbar paraspinal muscles
**Loss of normal lumbar lordosis
**Worsening of pain with hip flexion
**Concurrent ileus in some cases
*Diagnosis
**Elevated CK
**Elevated compartment pressures
**Imaging not required
***If imaging is performed, MRI is the test of choice
***MRI will demonstrate enhancement of the paraspinal muscles on T2-weighted images
***CT is less helpful, but can exclude other causes of low-back pain such as fracture
*Treatment is with emergent fasciotomy and with fluid resuscitation for any concurrent rhabdomyolysis <ref>Alexander W. et al. Acute lumbar paraspinal compartment syndrome: a systematic review. ANZ Journal of Surgery. 2018; 88: 854-859.</ref>
[[File:MRI Lumbar Paraspinal Compartment Syndrome.png|thumb|Magnetic resonance imaging (T1-weighted with gadolinium) showing edema and high signal intensity (arrows) in the region of the left multifidus and longissimus muscles.]]   

===Other===
*Thigh (quadriceps compartment) 
[[File:Compartments_of_the_Thigh.png|thumb|Compartments of the thigh]]
*Buttock (gluteal compartment) 
*Arm (deltoid, biceps compartments) 
*Abdominal

==Differential Diagnosis==
{{Extremity trauma DDX}}
{{Calf pain DDX}}

==Evaluation==
===Work-Up===
*X-ray to evaluate for fracture
*[[Compartment pressure measurement]] (take serial measurements if needed) 
*Total CK ([[rhabdomyolysis]]) 
*Chemistry ([[hyperkalemia]])

{{Compartment Pressure Interpretation}}

==Management==
#Fasciotomy 
#*Perform as soon as diagnosis is made by history/physical or by measurement 
#*Permanent damage results from >8hr of ischemia
#*Refer here for technique: http://www.wheelessonline.com/ortho/12806
#Support blood pressure in hypotensive patient 
#Place affected limb at the level of the heart or slightly dependent 
#AVOID ice (will further compromise microcirculation) 
#Bivalve or remove cast if present
#Adequate analgesia
#Management for associated [[rhabdomyolysis]] if present

==Disposition==
*Admit

==See Also==
*[[Compartment Pressure Measurement]]
*[[Burns]]
*[[Rhabdomyolysis]]
*[[Fractures (Main)]]
*[[Abdominal compartment syndrome]]

==External Links==

==References==
<references/>
[[Category:Orthopedics]] [[Category:Trauma]]