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Compartment Syndrome

Compartment Syndromes

Compartment syndrome is characterized by development of pressure within a muscle compartment beyond limits. Such a process causes the blood flow to decrease giving rise to debilitating conditions.


Presentation

Severe pain is the classical symptom of compartment syndrome. The pain usually does not respond to over the counter medications. In addition, in severe cases, compartment syndrome may present with the following signs and symptoms [7]:

  • Weakness
  • Pain that gradually gets worse
  • Development of parasthesia in the affected area
  • Skin of the affected area turns pale
  • Experiencing great difficulty in moving the affected area
  • Experiencing severe pain when the affected area is stretched or pulled
Leg Swelling
  • Given the location and size of the aneurysm, the severe leg swelling, and venous hypertension, aneurysmorrhaphy or aneurysm sac excision with arterial reconstruction was prohibitively dangerous.[ncbi.nlm.nih.gov]
  • Symptoms can include: cramping pain during exercise, most often in the legs swelling or a visibly bulging muscle a tingling sensation the affected area turning pale and cold in severe cases, difficulty moving the affected body part When to get medical[nhs.uk]
Streptococcal Infection
  • The patient was immediately taken to the operating room for decompressive fasciotomy, debridement, drainage, and irrigation of what cultures subsequently revealed to be a virulent streptococcal infection.[ncbi.nlm.nih.gov]
Recent Dental Work
  • Further investigation found her to be suffering from endocarditis and she had had recent dental work. Presentation and management is discussed, with learning points highlighted.[ncbi.nlm.nih.gov]
Calf Pain
  • CASE: A 15-year-old female competitive high school basketball player presented as an outpatient with a 3-month history of bilateral exertional calf pain.[ncbi.nlm.nih.gov]
  • CASE REPORT A 28-year-old man presented to the Emergency Department complaining of severe calf pain after exercising. In addition to his prescription medications, which included sertraline, he also consumed dietary supplements prior to his workout.[ncbi.nlm.nih.gov]
  • He reported that he did not have calf pain or discomfort during such activities 13 months postoperatively. The authors obtained a follow-up exercise magnetic resonance image.[ncbi.nlm.nih.gov]
  • Pain Shin Pain Achilles Injuries Achilles Tendonitis / Tendinitis Achilles Tendon Rupture Retrocalcaneal Bursitis Calf Pain Calf Muscle Tear Shin Pain Shin Splints Stress Fracture Tibialis Posterior Tendinopathy Muscle Injuries Compartment Syndrome Muscle[physioworks.com.au]
  • Clinical diagnosis is hard because patients usually present with 1 of these signs and the rest when it is “too late” 6ps : PAIN , Pallor, Pulselessness, Paresthesias, Paralysis, Perishingly cold/Pudgy calf Pain is the earliest sign/ Pain w/ passive stretching[sinaiem.org]
Muscle Tenderness
  • Severe pain during exercise that typically goes away an hour after stopping Pain on both sides of the body, such as in both legs Fullness or tightness in the muscle Tender, aching muscles Muscle weakness Numbness, tingling In severe cases, foot drop—a[uvahealth.com]
  • Symptoms may include: Severe pain during exercise that typically goes away an hour after stopping Pain on both sides of the body, such as in both legs Fullness or tightness in the muscle Tender, aching muscles Muscle weakness Numbness, tingling In severe[cancercarewny.com]
  • Muscle tenderness and swelling. Excessive pain on passive movement, increasing pain despite immobilisation. Peripheral pulses may still be present.[patient.info]
Myalgia
  • However, CCS patients may instead experience both increased leg pain and a proximal myalgia, which is possibly a referred pain.[ncbi.nlm.nih.gov]
Clonus
  • Physical examination revealed tachycardia, tachypnoea, diaphoresis, rigidity, hyperreflexia and clonus. Given the fast onset of symptoms, a diagnosis of serotonin syndrome was made.[ncbi.nlm.nih.gov]
Complex Regional Pain Syndrome Type II
  • Based on clinical findings, he was diagnosed with complex regional pain syndrome type II, or causalgia, and was referred for a lumbar sympathetic block under fluoroscopic guidance. Sympathetic block resulted in relief of the patient's symptoms.[ncbi.nlm.nih.gov]

Workup

In majority of the cases, physical examination of the signs and symptoms would be enough to diagnose the condition. No kind of laboratory workup is indicated. In physical examination, the pressure in the compartment is directly measured with the help of needle that is attached to pressuremeter. The pressure in the compartment is measured before and after the activity [8].

In case of acute compartment syndrome with associated trauma physical examination along with the following analysis becomes necessary:

  • Renal function analysis
  • Urinalysis
  • Creatine phosphokinase
  • Urine myoglobin
  • Concentration of creatine phosphokinase of about 1000 to 5000 U/mL suggests the onset of compartment syndrome. 

Treatment

For acute compartment syndrome, surgery is the only available option to treat the condition. In this method, long incisions are made in the affected area to release the pressure. The wounds are usually covered with a sterile bandage and are closed in a second surgical procedure [9].

In case of any bandage or cast that is causing the condition, it should be loosened to relieve the pressure. Medications such as opioids and NSAIDs can be administered for providing relief from pain [10]. It is advised that side effects of the medications should be considered before prescribing to patients.

Prognosis

Prognosis of the condition largely depends on when the condition was diagnosed and when was the treatment initiated. In a research study, it has been reported that complete restoration of limb function could be attained when fasciotomy was carried out within 6 hours of injury [6]. When the treatment is not initiated within 12 to 24 hours of compression, then permanent damage to the nerve and muscles can occur.

Etiology

Development of excessive pressure inside a muscle compartment causes compartment syndrome. There are several factors that lead to increase in the pressure; these include: Fractures, injuries, infections, development of muscular hypertrophy, prolonged limb compression and burns causing development of acute compartment syndrome.

Chronic compartment syndrome is a common phenomenon for athletes and occurs due to repetitive movements or activities such as running, exercising, cycling and playing sports. All these can cause pressure inside the muscle to increase causing pain and tightness in the affected areas [2].

Epidemiology

The exact prevalence of compartment syndrome is not known. It has been reported that patients who have suffered vascular injury are more prone to develop compartment syndrome. It has been estimated that about 19% patients with vascular injury required fasciotomy to treat acute compartment syndrome [3]. In a study of military personnel of United States, it has been reported that about 4100 cases of chronic form of compartment syndrome occurred between the years 2006 to 2011 [4].

Sex distribution
Age distribution

Pathophysiology

Muscles of the arms and legs are separated by thick layers of tissue known as fascia. Each individual layer of fascia consists of a confined space known as the compartment. This compartment contains muscle nerves, blood vessels and tissues. All these are closely covered by the fascia. It is necessary to understand that there is no way through which fascia can expand.

As a result when pressure builds up inside a compartment, the muscles, nerves and blood vessels are compressed. When the pressure increases beyond limits, the blood flow is restricted causing permanent damage to the nerves and muscles. In such cases, if treatment is not initiated on time then the muscles unable to bear any more pressure undergo atrophy. As a result amputation of the affected limb would be the only available alternative [5].

Prevention

So far no guidelines have been given to prevent the development of compartment syndrome. However, with early diagnosis and prompt initiation of treatment the onset of complications can certainly be prevented.

Individuals with casts should be told in advance about the swelling that can develop. If such patients experience pain under the cast, then they should immediately seek medical advice.

Summary

Decrease in the blood flow due to pressure buildup in a muscle compartment limits the supply of oxygen and nutrition to the nerves and the muscle cells. Timely initiation of treatment is necessary; failure to do can cause incapacitating complications to set in. Compartment syndrome can be acute and chronic in nature. Acute form of compartment syndrome is a medical emergency requiring prompt treatment. On the other hand, the chronic form is less severe and is also known as exertional compartment syndrome [1].

Patient Information

Definition

Compartment syndrome is described as excessive increase in the pressure within a muscle compartment. The consequent buildup of pressure in the compartment can call for restricted blood flow which in turn can cause muscles and nerve damage. Compartment syndrome can be acute or chronic in nature.

Cause

The cause of pressure buildup within the muscles can be attributed to trauma resulting from injury or accidents. Chronic compartment syndrome is more common among athletes and occurs due to repetitive activities and carrying out heavy exercises. In such cases, the pressure increases in the compartment only during such activities. The body parts most commonly affected by this condition include the forearm and the lower leg. However, in some instances it can also affect the thigh, upper arm, hand and foot.

Symptoms

One of the most classical symptoms of compartment syndrome includes development of severe pain in the affected area that gets worse and does not fade away with medications. In addition, individuals also experience feeling of numbness, burning or tingling sensation in the affected area. It also becomes difficult to remove the part of the limb that is affected.

Diagnosis

In most cases physical examination is enough to diagnose the condition. However, many a times analyzing the creatine phosphokinase levels and evaluating kidney functioning is also required.

Treatment

Surgery is often the method of choice to treat compartment syndrome. It is employed to prevent permanent damage to the affected area. Pain relieving medications are also administered depending on the patient’s profile.

References

Article

  1. Matsen FA 3rd. Compartmental syndrome. An unified concept. Clin Orthop Relat Res. Nov-Dec 1975;8-14.
  2. Black KP, Schultz TK, Cheung NL. Compartment syndromes in athletes. Clin Sports Med 1990; 9:471
  3. Sheridan GW, Matsen FA 3rd. Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am. Jan 1976;58(1):112-5.
  4. Waterman BR, Liu J, Newcomb R, et al. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med 2013; 41:2545.
  5. Rorabeck CH, Macnab I. The pathophysiology of the anterior tibial compartmental syndrome. Clin Orthop Relat Res. Nov-Dec 1975;52-7
  6. Almdahl SM, Samdal F. Fasciotomy for chronic compartment syndrome. Acta Orthop Scand 1989; 60:210.
  7. Hutchinson MR, Ireland ML. Common compartment syndromes in athletes. Treatment and rehabilitation.Sports Med. Mar 1994;17(3):200-8.
  8. Barnes M. Diagnosis and management of chronic compartment syndromes: a review of the literature. Br J Sports Med 1997; 31:21.
  9. Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med 1993; 21:811.
  10. Liem NR, Bourque PR, Michaud C. Acute exertional compartment syndrome in the setting of anabolic steroids: an unusual cause of bilateral footdrop. Muscle Nerve. Jul 2005;32(1):113-7.

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Last updated: 2017-08-09 14:47