Compartment Syndrome: A Case Study

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. 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. 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. 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.

References

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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.