SUMMARY: Compartment Syndrome may be a complication of limb fractures and crush injuries. Early diagnosis requires physician awareness, repeated clinical reassessment and specific testing. Delayed diagnosis and treatment increases the probability of permanent deformity and disability.
Compartment syndrome is a condition in which blood supply to muscles and nerves is pinched off, because the pressure increases in a tissue space (compartment) that cannot expand.
Unrelieved, the compromise to the local circulation of blood results in permanent tissue destruction.
Anatomical sites that are vulnerable are those bordered by bone and fascia (sheets of fibrous tissue) in the limbs and back.
Personal injury lawyers are most often concerned with compartment syndrome following acute injury, and by far the commonest site is the lower leg following fracture of the tibia.
Nevertheless, all major parts of the limbs, including shoulder and buttock, have such compartments, and Compartment Syndrome has been described in all these anatomical locations.
Typically, the condition is triggered by bleeding, soft tissue injury or external compression.
Resultant swelling prevents drainage of blood from the tissues of the compartment.
The increasing tissue pressure compromises blood supply to the tissue.
If the pressure is relieved within 12 hours, recovery is more likely to be complete(1).
Practice PointEarly diagnosis and treatment, certainly within 12 hours, is mandatory
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A subrogated Action for surgical malpractice might then be appropriate.
The cardinal symptom is increasing (crescendo) pain with a severity disproportionate to the original injury(2).
This symptom is not helpful in an unconscious patient, or when there is accompanying nerve damage(3). Similarly, warning pain may be masked by strong pain relief, particularly Patient Controlled Analgesia (PCA) that is commonly provided after orthopedic surgery3a. Indeed, a case can be made for routine intermittent or continuous3b compartment pressure monitoring when using PCA.
Even without those complications, absence of such pain should not be relied on to exclude compartment syndrome(4).
Numbness, tingling and tenseness of the injured part may follow.
Practice PointCompartment Syndrome symptoms: 1. Crescendo pain |
A "wooden" texture on feeling through the skin (palpation) deep in the compartment is characteristic(6).
Paleness of the overlying skin and loss of pulses are late signs.
Large blisters (bullae) occur late and inconsistently.
Practice PointCompartment Syndrome signs: 1. Diminished sensation |
The enzyme Creatine PhosphoKinase (CPK) is released by damaged muscle, and blood levels should be routinely tested(7) when the diagnosis is suspected.
Myoglobin, the oxygen-carrying pigment of red muscle, may appear in the urine.
Practice PointCompartment Syndrome tests: 1. Creatine PhosphoKinase (CPK) |
Various devices are used to directly measure compartment pressure(2), though the pressure at which surgical intervention should be undertaken is controversial(8).
Pressures are measured continuously, or intermittently every 1-4 hours.
External compression devices for treatment of accompanying injuries should be removed, and low blood pressure corrected.
Immediate surgical or orthopedic consultation is mandatory, and the definitive surgical treatment is fasciotomy, release of pressure by incising (cutting into) the sheet of fascia.
Delayed diagnosis and treatment increases the probability of permanent deformity and disability.
Between 1% and 10% of occurrences of compartment syndrome progress to permanent deformity and weakness(9).
Volkmann's Contracture has two components.
The affected muscles are shortened by destruction of muscle tissue and resultant scarring.
Paralysis Caused by nerve damage may also affect muscles beyond ( distal to) those shortened by scarring.
Volkmann's Contracture may be palliated by various non-surgical and surgical interventions(10).
Non-operative therapy is directed at increasing and maintaining joint movement and muscle strength, and minimising the effects of deformity by providing bracing, customised foot wear and other prosthetics.
Operative interventions include relief of nerve compression or persistent muscle deformity.
In the worst cases, bone removal ( osteotomy) or amputation may be required.
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