Compartment

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

• 10 hour long supine position • Erythema localized to

right buttock
• Intubated in PACU overnight
• Swollen R buttock
(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

•Superficial Posterior
• Gastrocnemius and soleus muscle.
Sural nerve Figure 1. Cross-section Medial Calf. Adapted from “Grey’s Anatomy,”
• Lithotomy positions 2009. Retrieved from : https://radiopaedia.org/images/24012
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 – Thigh
• Anterior
• 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

common pathway: cellular anoxia 
death of the muscle within compartment.
ISCHEMIA
 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
dressings/tourniquet
• Crush Injury
• Burns
• Hemorrhage
(anticoagulation, • Injection
injury/Extravasation
intramuscular injury)
• Intra-osseous infusions
• Less common causes… r/t
fluid retention – • Infection
rhabdomyolysis, muscle
hypertrophy, DVT • Surgical positioning
 Clinical Presentation
6 P’s

Pain Pallor

Pressure Pulselessness

Paresthesia Paralysis
 PAIN
• 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
PARESTHESIA

• A condition in which you

feel sensation of numbness
or prickling

• Pins & Needles

• Early contained to one

compartment
• Late globally within limb
 PALLOR

• 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
 PARALYSIS
• 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

intracompartmental myoglobinuria
pressure
 Diagnosis

Stryker Manometer is
most commonly used
• Normal at rest
0 - 10 mmHg
• Pressures > 30-
40mmHg require
surgical
decompression,
combined with
supporting clinical
https://www.slideshare.net/drrohitvikas/compartment-syndrome-14077010
picture
 Support Your Case
• What are the • Can use measure the
precipitating pressure within the
factors? compartment?
• Is it >30 – 40
• Is this a high risk mmHg?
patient?
• Additional helpful
• Imaging objective information
• MRI/CT scan can • Elevated creatinine
show swelling of phosphokinase
the gluteal muscles (CPK) indicates
muscle damage or
ischemia
 Treatment

• 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

 References
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