Compartment Syndrome Treatment

Synopsis

Acute compartment syndrome is a surgical emergency with diverse etiologies. Acute compartment syndrome is classically described clinically with “the 6 P's”: pain, pallor, paresthesia, paresis, poikilothermia, and pulselessness. Clinical examination along with judgment is the gold standard for diagnosis; however, suspicion of compartment syndrome can be confirmed by measurement of intracompartmental pressures. The definitive treatment of acute compartment syndrome is early fasciotomy. Delayed or inadequate treatment can lead to poor outcomes, including limb amputation, poor motor and sensory nerve function, debilitating contractures, or even multi-organ failure and death. In this chapter, the pathophysiology, etiologies, diagnosis, and treatment of upper-extremity compartment syndrome are reviewed.

Clinical Problem

Compartment syndrome is a surgical emergency with many etiologies that share a distinct clinical picture. In its most basic definition, acute compartment syndrome (ACS) results when there is increased pressure within a fascia-enclosed tissue space that compromises the blood flow to the tissues inside of the compartment. ACS can commonly arise from any number of major traumas (especially those with crush mechanisms), fractures, and burn/electrical injuries, as well as post-surgical revascularization of ischemic limbs. Among other etiologies, it can also be a sequela of internal space-occupying lesions such as tumors, hematomas, abscesses, and extravasation of intravenous fluids or contrast, as well as external causes such as casts and dressings that are placed too tightly. A systematic review of forearm compartment syndrome cases found that the most common cause of ACS of the forearm in children was a supracondylar fracture, whereas in adults the most common cause was distal radius fracture.

Physiologically, a capillary perfusion pressure of approximately 25 mm Hg maintains the oxygen level needed for normal tissue metabolism, which is above the normal interstitial tissue pressure of 4 to 6 mm Hg. The tissue perfusion pressure equals capillary perfusion pressure minus interstitial pressure. Interstitial tissue pressures above 30 mm Hg overwhelm capillary perfusion pressure, causing progressive blood vessel collapse. This, in turn, leads to compromised tissue perfusion pressure, a local tissue oxygen deficit, and an ischemic insult. Early compartment fasciotomy decompression allows tissues under excess pressure to expand, leading to a drop in interstitial pressure, restoration of local blood flow, clearing of toxic anaerobic metabolites, and return of normal cellular function.

Clinically, patients will present with varying symptoms and degrees of severity depending on the etiology of the compartment syndrome. The following section will further elaborate on the physical examination findings to diagnose ACS.

Pre-Operative Management