By Christopher Ebright
Case
You are called to a scene where a skier has fallen. The male patient is in moderate distress and complaining of lower left leg pain. Assessing the limb, you see there is a closed tibia/fibula fracture with obvious deformity. Noticeable swelling, when compared to the right leg, is observed. Additionally, a thready pulse is palpated distally with delayed capillary refill. What could be going on?
Crush injury is sustained from a compressive force sufficient to interfere with the normal metabolic function of the involved tissue. The systemic manifestation is called crush syndrome, while the local manifestation is called compartment syndrome. We will focus on the latter.
There are numerous causes for compartment syndrome (CS), including burns, tight casts, infections, snakebites, blunt soft tissue injury, intravenous or intraosseous infiltration, and prolonged immobilization. (2) Fractures are the most common cause, resulting in 2-9% of tibial fractures we see in CS. (4) When CS develops, it can have disastrous consequences, including loss of the affected limb.
Pathophysiology of Compartment Syndrome
Skeletal muscle groups are covered by a tough, relatively inflexible membrane called fascia. It is a sheet of connective tissue beneath the skin that attaches, stabilizes, encloses, and separates muscles and other internal organs. (1) This separation forms parallel “tunnels” within the length of the limbs. It is within these tunnels (compartments) where we find blood vessels, nerves, and lymphatic vessels.
Damage to a muscle group sometimes will cause swelling of the fascia and bleeding into the compartments. Due to its structural makeup, fascia stretches very little. When it swells, the resultant pressure pushes inward, collapsing the compartments. Bleeding floods into the compartments, compressing the blood/lymphatic vessels and nerves. As the compartment continues to fill, lymphatic, capillary, and small venule flow decrease, followed by reduction in the venous and arterial flow. (3) Without a steady supply of oxygen and nutrients, proximal and distal nerve and muscle cells become ischemic and can die within a matter of hours.
Once compartment syndrome starts to develop, it can manifest in many ways. Pain, out of proportion to the injury, is the most common symptom. Often described as severe, burning, and intense; it may be worsened with movement, palpation, pressure, or passive stretching of the affected limb. Distal to the injury; pale skin, paresthesia, pulselessness, delayed capillary refill, and paralysis may also be present. Some cases will also present with significant swelling, as well as motor and sensory deficits.
Management of Compartment Syndrome
After all life-threatening airway, breathing or circulation issues are addressed, care for these patients is somewhat limited. Prompt recognition of compartment syndrome is paramount. Appropriately manage the underlying issue causing the development of compartment syndrome (fractures, etc.). Remove any constricting clothing, dressings or jewelry and keep the affected limb at heart level. (5) Cold application may be useful for pain management as well as slowing any further swelling. ALS providers may also consider IV pain management. Fentanyl is recommended over morphine, due to the possible vasodilatory side-effects. Transport to an appropriate medical facility, giving as much advanced notice as possible.
Summary
Compartment syndrome is a time-sensitive surgical emergency caused by increased pressure within a closed compartment.
ACS is associated with a number of risk factors but occurs most frequently after a fracture or trauma to the involved area.
Pain out of proportion to the injury, paresthesia, pain with passive stretch, focal motor or sensory deficits, or decreased pulse or capillary refill time are signs and symptoms concerning for ACS.
Prompt recognition of compartment syndrome and transportation to an appropriate facility are important interventions to improve long-term outcomes.
About Christopher
Chris Ebright is an EMS Education Coordinator with the National EMS Academy in Covington, Louisiana. He is a Nationally Registered paramedic for over 24 years, providing pre-hospital emergency care ranging from primary EMS response to critical care transportation by land and air. Chris has also educated first responders, EMT’s, paramedics, nurses and doctors for over 23 years.He holds Bachelor of Education degree from the University of Toledo in Toledo, Ohio and is currently an annual presenter at local, state,and national EMS/Public Safety conferences.
He is a self-proclaimed sports, rollercoaster and movie junkie and enjoys traveling as often as possible throughout the United States.
References
1. Marieb, Elaine Nicpon; Hoehn, Katja (2007). Human Anatomy & Physiology. Pearson.
2. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000 Mar;82(2):200-3.
3. Marchesi M, Marchesi A, Calori GM, et al. A sneaky surgical emergency: Acute compartment syndrome. Retrospective analysis of 66 closed claims, medico-legal pitfalls and damages evaluation. Injury. 2014 Dec;45 Suppl 6:S16-20.
4. Lollo L, Grabinsky A. Clinical and functional outcomes of acute lower extremity compartment syndrome at a Major Trauma Hospital. Int J Crit Illn Inj Sci. 2016 Jul-Sep;6(3):133-142.
5. Long B, Gottlieb M. The Dreaded Acute Compartment Syndrome. EmDocs. 2018 Oct.
