Compartment syndrome

CS can occur in any muscle compartment, most commonly the lower leg and forearm.

• Tibia fractures – up to 48 hours after injury
• Tibia fractures – up to 48 hours after fixation
• Forearm fractures
• High energy wrist fractures
•  Crush injuries
• Reperfusion to ischaemic limbs
• Prolonged immobilisation or a ‘long lie’
• Restrictive dressings/casts.

Pulses - Pulses are normally present in CS. Absent pulses are usually due to:

• Systemic hypotension
• Arterial occlusion
• Vascular injury

Palpably tense compartments may suggest CS, but its absence does not rule out CS; this clinical finding is also highly subjective.

Open fractures even with traumatic fasciotomy open tibia fractures have higher rates of CS than closed fractures.

Regional anaesthesia and analgesia – Avoid where possible in patients at elevated risk for compartment syndrome.

Foot CS – There is no consensus on management.

The cardinal features of compartment syndrome are:

• Pain out of proportion to the associated injury
• Pain on passive movement of the muscles within the affected compartment.

Pain may be difficult to assess in patients with fractures. Clinicians should be alerted to any paraesthesia / reduced sensation in the distribution of nerves within the affected compartment.

• Assess pain scores hourly for all patients. Considering the amount of opiates used and the response to opiates.
• Seek immediate senior orthopaedic opinion (ST4+) if any of the following:
  
  • Pain scores not improving
  • Increasing opiate use
  • Poor response to opiates.

As well as pain also document the following hourly:

• Neurology
• Capillary Refill Time
• Peripheral pulses
• Compartment pressures (when a compartment monitor has been placed).

None of these findings contribute to early diagnosis.

Initial Management

• Remove all circumferential dressings to skin
• Elevate limb to heart level
• Maintain a normal blood pressure
• Re-assess after 30 minutes.

Re-assessment at 30 minutes

If clinical signs/symptoms persist there are two options:

• Immediate surgical decompression or
• Placement of a compartment monitor if not already in place or if the clinician is not convinced by clinical signs/symptoms.

Indications - Place a compartment monitor into the compartment of concern in patients with high-risk features and the following:

• Reduced level of consciousness / clinical assessment unreliable
• Regional anaesthesia has been performed
• If clinical signs/symptoms remain unconvincing.

Indications

• A clear clinical diagnosis. A Compartment Perfusion Pressure <30mmHg (Diastolic blood pressure- compartment pressure) is highly suggestive of the need for surgery and only a consultant should decide to continue monitoring in this situation.
• A compartment pressure >40mmHg with symptoms also requires senior review.

Contra-indications

CS >12 hours of warm ischaemia with non-viable muscle should not routinely undergo fasciotomy. The role of amputation is unclear in this situation and aggressive medical management should be instituted.

Timing - Compartment syndrome is a surgical emergency and surgery should occur within 1 hour of the decision to operate.

Early Plastics involvement – Consider involving a plastic surgeon as soon as the decision to operate is made. Open fascial decompression of all involved compartments, considering possible reconstructive options.

Procedure - Excise all necrotic muscle. Document the compartments decompressed.

Lower leg fasciotomies – Perform a two incision four-compartment decompression.

Incomplete lower leg fasciotomies cause significant morbidity. The common reasons are:

• Identification of the septum dividing the anterior and lateral compartments. This can be avoided by making an initial transverse incision in the fascia overlying the septum, then deliberately opening the anterior and lateral compartments separately, creating a so-called “H” incision.
• Incomplete development of the deep posterior compartment release by not deliberately taking the soleus muscle fibres off the posterior tibia. If performed correctly, the neurovascular bundle should be exposed in a fully decompressed deep posterior compartment.
• Fascial incisions are too short and do not cover the entire extent of the fascial compartment, either at the knee or ankle levels.

Re-look – Re-explore at 48 hours (or earlier if indicated).