Extremity Compartment Syndrome

 
Acute compartment syndrome is a surgical emergency caused by an increase in the interstitial pressure within a closed muscle compartment of an extremity causing decrease perfusion of muscles and nerves. It can be the result of external compressing or internal expansion forces within an enclosed fascial compartment. Most cases of compartment syndrome are associated with trauma (80%), namely tibial and forearm fractures followed by nontraumatic causes (20%) such as ischemic-reperfusion event after arterial injury, thrombosis, burns, bleeding disorder, infection and blunt injury. The normal pressure in a muscle compartment is less than 12 mm Hg. Swelling of injured muscle raises the intracompartment pressure closing lymphatics vessels and small venules. Early presentation there is perifascicular and intrafascicular edema, hypertension in the capillary bed, and compression of arterioles, all of which worsen the ischemia. Blood flow in the capillary circulation ceases when compartment pressures exceed 35 mm Hg. The sensory nerves are affected first, followed by the motor nerves and muscles, fat and skin become involved later. The skin is the most resistant to ischemia. Untreated compartment syndrome causes irreversible neurologic damage, muscle necrosis, myoglobinuria, renal failure and fibrous contracture (Volkmann). Symptoms include pain, pallor, paresthesia, paralysis and pulselessness. Management consists of urgent decompressive fasciotomy. Measurement of the compartment pressure by needle or using near-infrared spectroscopy showing values higher than 30 mm Hg (or 20 mm Hg below diastolic pressure) should undergo fasciotomy. For upper limbs decompression can be achieved via volar or dorsal approach or both. In the lower extremity four-compartment decompression can be achieved b a single or double incision technique. Decompression of the thigh can be achieved via medial or lateral incision. Complications of fasciotomy include infection, iatrogenic nerve or blood vessel injury and muscle damage. Complications associated with the fasciotomy scar includes paresthesia, pruritus and pain.

References:
1- Ramos C, Whyte CM, Harris BH: Nontraumatic compartment syndrome of the extremity in children. J Pediatr Surg 41: E5-E7, 2006
2- Dover M(1), Memon AR, Marafi H, Kelly G, Quinlan JF: Factors associated with persistent sequelae after fasciotomy for acute compartment syndrome.J Orthop Surg (Hong Kong). 20(3):312-5, 2012
3- Erdos J, Dlaska C, Szatmary P, Humenberger M, Vilmos V, Hajdu S: Acute compartment syndrome in children: a case series in 24 patients and review of the literature. Int Orthop. 35(4):569-75, 2011
4- Tharakan SJ, Subotic U, Kalisch M, Staubli G, Weber DM: Compartment Pressures in Children With Normal and Fractured Forearms: A Preliminary Report. J Pediatr Orthop. 36(4):410-5, 2016
5- von Keudell AG, Weaver MJ, Appleton PT, Bae DS, Dyer GSM, Heng M, Jupiter JB, Vrahas MS: Diagnosis and treatment of acute extremity compartment syndrome. Lancet. 386(10000):1299-1310, 2015
6- Elmhiregh A, Feghih AE, Faraj K: Concomitant unilateral post-traumatic leg and foot compartment syndrome in a 5 years-old child - Case report. Int J Surg Case Rep. 33:151-157, 2017


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