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Compartment Syndrome

 

Compartment syndrome is an increased pressure in a closed space or a compartment which will result in decreased perfusion and ischemia to the muscles and nerves. Compartment syndrome is an increased pressure in a closed space or a compartment which will result in decreased perfusion and ischemia to the muscles and nerves. This may cause irreversible damage to the contents of that closed space. Eventually, it may lead to Volkmann’s ischemic contracture. At the muscle level, ischemia for 4 hours can cause damage, but this damage is reversible. Compartment syndrome for 4-6 hours will cause ischemia. Compartment syndrome for 8 hours will cause irreversible damage; this is why it is a surgical emergency. Compartment syndrome for 1 hour, there will be normal conduction violocity. 

CS for 1-4 hours, this can cause reversible damage. CS for 8 hours, there will be irreversible damage to the nerves. Compartment syndrome can be caused by increased volume. The volume increases by hemorrhage inside the muscle or swelling, seen in fractures such as fracture of the tibia or fractures of the forearm, or the muscle injury will cause edema and this will increase the volume inside the compartment. It can also be caused by decreased volume of the compartment due to a tight cast or tight dressing. A high index of suspicion is necessary to diagnose compartment syndrome. You will go over the history of the patient and do physical examination. You will find that there is pain that is out of proportion to the pain expected from the injury or the surgery. Pain is getting worse and is not being relieved by analgesics. The extremity should be examined for swollen and tense compartment and pain with passive stretch. Paralysis and no pulse are both late findings which indicates that the damage may be irreversible. If the compartment pressure is greater than 30 mmHg (absolute measurement), or within 30 mmHg of the diastolic pressure, then immediate fasciotomy should be done. The highest pressure is usually at 5 cm from the injury or the fracture.


I usually measure all the compartments. To treat compartment syndrome, you must remove the bandage and the dressings then split the cast. Examine the patient. Once the diagnosis is established, you need to do a four compartment fasciotomy. Fasciotomy can be done with the classic two incisions it can be done with one incision. All four compartments must be released. Fasciotomy must be done urgently. Fasciotomy should be done in the operating room, but if necessary, you can do bedside fasciotomy. The incision should be made half way between the tibia and the fibula. You should release the anterior compartment and the lateral compartment. The superficial posterior compartment is located and released after retracting the peroneal muscles anteriorly. A Cobb or retractor may be used for this purpose. The deep posterior compartment is released by retracting the tibialis anterior muscle laterally from the tibia, then incising the interosseous membrane. When you feel the posterior aspect of the tibia that means that the posterior compartment is released and entered.
 

Author
Nabil Ebraheim, MD

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