REVIEWAcute compartment syndrome of the limb
Introduction
Matsen defined the compartment syndrome as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.”24
Malgaigne was the first to describe compartment syndrome, and the first medical reference was by Volkmann39 in 1881. Jepsen reported successful treatment by decompression18 in an experimental study.
The abdominal compartment syndrome was first described by Baggot in 1951.4 The increasing intra-abdominal pressure alters cardiovascular haemodynamics, respiratory mechanics and renal function.
In this review, only the aetiology, clinical signs, diagnosis and treatment of the limb compartment syndromes are discussed.
Section snippets
Aetiology and incidence
Most compartment syndromes are associated with traumatic insults, but the condition also occurs after reperfusion, following a period of ischaemia, burns, prolonged limb compression after drug abuse or poor positioning during prolonged surgical procedures (Table 1).
This classification, based on aetiology, is a simplification; in most cases, a combination of factors is responsible.11., 37.
Pathophysiology
The normal pressure in the muscle compartments is below 10–12 mm Hg (4–21).42 The compartmental perfusion pressure, which is the mean arterial pressure minus the compartment pressure, should be above 70–80 mm Hg.17., 23.. Both increasing the compartmental pressure and decreasing the perfusion pressure can lead to a compartment syndrome. Swelling of the injured muscle and soft tissue raises the intra-compartmental pressure, closing the lymphatic vessels and the small venules. Hypertension in the
Symptoms and signs
The initial clinical signs of compartment syndrome are often subtle. Early diagnosis requires a high index of suspicion. Pain, usually out of proportion to the injury, can be the first indication of compartment syndrome. The six P’s, formerly emphasised by Mubarak and Rorabeck,, are very late signs, usually at an irreversible stage29 (Table 2).
Remember that these signs can be elicited only in the fully conscious patient. Early diagnosis is difficult in patients with CNS compromise, the very
Diagnosis
For a good clinical outcome, early diagnosis is of paramount importance. In patients with early symptoms, such as increasing pain, paraesthesiae and pain on passive stretching, careful and frequent assessment is necessary. If this is impossible, then prophylactic fasciotomy may well be indicated. It is certainly recommended in patients with an interrupted arterial supply lasting more than 4–6 h, in patients who are unconscious, or have periphereal nerve injuries, and in patients who undergo open
Laboratory parameters
Seriously elevated levels of creatinine phosphokinase (CPK) may indicate severe muscle damage, or ischaemia. In absence of clinical signs, it could indicate an unsuspected compartment syndrome. For early diagnosis, it is clearly not helpful.
Compartment pressure
If the diagnosis is clinically evident, it is not necessary to measure the compartment pressures. This should be undertaken only when the clinical signs are unclear, and in patients whose consciousness level is impaired.
Measurement by saline injection was first done by French and Prince in 1962.14
Both needle techniques3., 40. and catheter techniques31 require a bubble-free column of saline, and the tip may become blocked by muscle and blood clot. The catheter systems provide a continuous
Other methods
Willy et al.42 showed the easy and highly accurate use of transducer tipped probes. They work without the artefacts associated with saline-column systems. It is also possible to measure the partial pressure of oxygen in the muscle with catheters, although this method is not routinely used clinically, as the critical levels of tissue oxygenations have not yet been defined or validated, and its worth has to be proven. Theoretically, it should be helpful to measure the oxygen saturation in the
Critical pressure
More important than improving the technical devices is to improve the guidelines for interpretation of the results and their clinical relevance.
The critical level of the absolute intra-compartmental pressure remains yet undecided. In the literature, levels ranging from 30 to 50 mm Hg are proposed.1., 29., 31. Experimental studies have shown a big difference between individuals, when correlating absolute pressure levels, clinical signs, nerve function (EMG) and oxygen levels in the muscle tissue.
Surgical therapy
If compartment syndrome is suspected, all circumferential dressings should be removed, normal blood pressure should be achieved by dealing with any cause of hypotension. The extremity should not be elevated, but kept at heart level, in order to maintain perfusion in the compartment. Supplementary oxygen, to improve the tissue oxygenation, is helpful.
If the Δp is below 30 mm Hg, and/or clinical signs are present, fasciotomy of all relevant compartments is the treatment of choice and should be
Summary
The final clinical outcome of an untreated compartment syndrome is the replacement of muscle with scar tissue. This produces a severe fibrous contracture and a neuropathy of any peripheral nerve traversing the compartment, leading to serious dysfunction. Once this stage is reached, it is never possible to restore normal function.
For early detection of muscle compartment syndrome, it is necessary to educate those taking care of patients at risk, especially in the early symptoms and signs.
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