Compartmental syndrome. An unified concept.

A compartmental syndrome is defined as a condition in which increased pressure within a space compromises the circulation to the contents of that space. Any cause of increased intracompartmental pressure may result in a compartmental syndrome. The diagnosis should be suspected in any case of pain or neuromuscular deficit in an extremity and may be confirmed by signs of circulatory disturbance of nerve and muscle in association with increased pressure in the compartment. Generous opening of any dressings covering the extremity permits a proper examination and rules out a compartmental syndrome caused by the dressing itself. Immediate decompression is indicated in all cases of compartmental syndrome unless the risk of complications exceeds the possible gains from improvement in circulation. Elevation of an extremity afflicted with a compartmental syndrome is contraindicated. Myoglobinuria and renal failure may complicate severe cases.     

Mechanical impedance: a new, noninvasive method for measuring tissue pressure in tibial compartment syndrome. I. Physical principles and results of an animal experiment

The basic factor involved in the development of compartmental syndrome is increased tissue pressure, which leads to impairment of microcirculation, the ultimate cause of muscle cell necrosis, In practice, however, the technical side of pressure measurement has its problems since the current invasive methods using intracompartmental catheters are always at risk of infection. It would be preferable to do the assessment in a noninvasive way from the exterior the pressure that prevails inside. An apparatus was developed to measure the mechanical impedance in the soft tissue layer above the anterior tibial compartment: an impedance head is applied to the overlying tissue with a defined initial pressure. The impedance head contains a driving probe that touches the skin, a receptor measuring force, and acceleration. The ratio of force and acceleration describe and record the mechanical impedance [Z = kg/s]. The accuracy of the appliance was tested in a test using the hindlegs of 21 rabbits with compartmental syndrome, which was induced experimentally by gel instillation. The mechanical impedance was measured under increasing tissue pressures in the anterolateral muscle. We performed a total of 100 gel instillations and 121 times the mechanical impedance was measured at a frequency of 20 Hz. The graphs of all 21 measuring series showed an average rise of 0.0243 kg/s per cm H2O. In general, all graphs showed a linear rise in the mechanical impedance that was proportional to the intracompartmentally measured tissue pressures.     

Monitoring of intramuscular pressure.

Increased pressure within an osteofascial compartment may produce a compartmental syndrome, one of the principal causes of local circulatory compromise in traumatized extremities. In certain instances, monitoring of intracompartmental pressure may be a valuable adjunct in the clinical evaluation of patients at risk for this syndrome.     

血氧饱和度监测与骨筋膜室内压测量在骨筋膜室综合征中的相关研究

目的：探讨血氧饱和度动态监测在骨筋膜室综合征的应用价值。方法：20例骨筋膜室综合征患者,其中男13例,女7例;年龄13-60岁,平均32岁;胫腓骨骨折13例,胫骨平台骨折3例,股骨骨折4例。用血氧饱和度仪动态监测指（趾）端血氧饱和度（SpO2）,同时采用改良Whiteside法测压装置监测骨筋膜室内压,对两组数据进行比较。结果：在20例骨筋膜室综合征中,血氧饱和度动态监测到的数据与骨筋膜室内压测到的数据呈负相关性,血氧饱和度越高,骨筋膜室内压越低,反之也一样。结论：应用血氧饱和度仪动态监测肢端SpO2的方法,能间接反映骨筋膜室内肌肉和神经的缺血情况,对骨筋膜室综合征作出早期诊断及处理。     

Mechanical impedance: a new noninvasive method for measuring tissue pressure in anterior compartment syndrome. II. Results of clinical measurements in patients with tibial trauma

In acute compartmental syndrome, it is difficult to decide on the basis of clinical criteria alone whether fasciotomy is indicated or not. Reliable and objective parameters are required before a treatment schedule can be devised. We tested mechanical impedance as a parameter for the pressure inside the tissue. The technique and associated apparatus for measuring mechanical impedance of the skin overlying the anterolateral compartment of the lower leg are described in detail. We performed the non-invasive measurement in 25 patients with leg injuries. There were 2 patients with acute compartmental syndrome and 5 with imminent compartmental syndrome. In normal legs, the mechanical impedance was between 2 and 6.5 kg/s, with an average of 3.83 kg/s. After the impedance is increased to 10 kg/s or higher, there is acute or imminent compartmental syndrome. Once the compartment has been decompressed by unilateral parafibular fasciotomy, the mechanical impedance decreases to normal values. Clinically relevant results were obtained by this method and they correlated well with the other clinical findings.     

Long-Term Results of Microscopic Lymphatic Vessel-Isolated Vein Anastomosis for Secondary Lymphedema of the Lower Extremities

Purpose To evaluate the effectiveness of microscopic lymphatic vessel-isolated vein anastomosis in patients with secondary obstructive lymphedema of a lower extremity, refractory to nonoperative management. Methods Nine women suffered from nonpitting edema of one or both legs (11 limbs) after radical hysterectomy with postoperative irradiation for uterine cancer. The indications for this operation were repeated cellulitis and severe nonpitting edema impairing limb function. Under microscopy of 3.2 on average, the identified lymphatic vessels were anastomosed to an isolated saphenous vein using the pull-through technique with modifications. Results The follow-up period ranged from 21 to 87 months and the operation achieved excellent reduction, of more than 5 cm, in six limbs; good reduction, of 2–5 cm, in two limbs; and poor reduction, of less than 2 cm, in three limbs. The frequency of cellulitis decreased from 2.4 infections per patient per year to 0.2 infections per patient per year. Conclusion These results show that microscopic lymphatic vessel-isolated vein anastomosis is a minimally invasive operation, with good long-term effects, making it the treatment of choice for intractable secondary lymphedema of the lower extremities refractory to physiotherapy.     

Compartment syndrome in multiple uninjured extremities: a case report

Compartment syndrome is a common problem in trauma patients. It can occur within any space bound by a dense fascial layer, such as the extremities or abdomen. It exists when increased tissue pressure within the limited anatomic space compromises perfusion. Failure to decompress the compartment leads to a self-perpetuating ischemia-edema process and resultant irreversible tissue damage. In the extremities, it typically arises from a vascular injury in that same extremity. Herein is reported a case of the unexpected development of compartment syndrome in multiple uninjured extremities in a trauma patient with hypotension requiring systemic vasopressors.     

Secondary extremity compartment syndrome

BACKGROUND: Abdominal compartment syndrome has been reported to occur after fluid resuscitation in injured patients, even in the absence of intra-abdominal injuries. This report describes a set of patients who developed the secondary extremity compartment syndrome (SECS) in uninjured extremities after resuscitation for other injuries. METHODS: This study was a retrospective chart review of all trauma patients developing SECS at a Level I trauma center. Data are mean +/- SD. RESULTS: From 1996 to 2001, 10 patients (8 men, age 31 +/- 13 years, Injury Severity Score of 29 +/- 17, and 3 with penetrating trauma) from a series of 11,996 trauma admissions developed SECS after resuscitation for other injuries. The mean number of extremities developing the SECS per patient was 3.1. This included compartment syndromes in 10 upper extremities and in 12 lower extremities that did not have any apparent injuries (i.e., contusions, fractures, or vascular injuries). After evaluation by the trauma team, abdominal silos were needed in 7 of the 10 patients also, and the mortality in patients with the SECS was 70%. CONCLUSION: SECS is a rare complication of the postresuscitation systemic inflammatory response syndrome, is associated with significant morbidity, and may be a marker for mortality. SECS should be ruled out by measurement of compartment pressures in uninjured and injured extremities in patients with severe diffuse edema after resuscitation for injury.     

The use of near-infrared spectrometry for the diagnosis of lower-extremity compartment syndrome

While intracompartmental pressure monitoring is a widely used diagnostic tool to measure intracompartmental pressures in the setting of compartment syndrome, its invasive nature has prompted the development of noninvasive techniques, such as near-infrared spectrometry. We prospectively assessed the association between tissue oxygen saturation measured by near-infrared spectrometry and compartment pressure measured by intracompartmental pressure monitoring in a cohort of patients with compartment syndrome of the lower extremity. We hypothesized that tissue oxygen saturation measured by near-infrared spectrometry would negatively correlate with intracompartmental pressures. Tissue oxygen saturation was determined for all 4 compartments of the lower extremity in 7 patients using near-infrared spectrometry. All patients subsequently underwent lower-extremity fasciotomies. Mechanism of injury, compartment pressures, blood pressure, near-infrared spectrometry measurement of tissue oxygen saturation, and characteristics of the muscle at the time of fasciotomy were recorded. The strength of the correlations between tissue oxygen saturation and absolute and relative compartment pressures was estimated based on mixed linear (growth) models with repeated observations nested within patients. Our analyses demonstrated no significant relationship between tissue oxygen saturation measured by near-infrared spectrometry and the absolute or relative compartment pressures. This suggests that compartment tissue oxygen saturation measurements by near-infrared spectrometry do not correlate with the diagnosis of compartment syndrome, and that near-infrared spectrometry would not serve as a reliable diagnostic tool.     

Compartmental pressure monitoring after arterial reconstruction lacks clinical relevance

Anterior compartmental intramuscular pressure was studied by the continuous-infusion technique during and after arterial reconstruction of the abdominal or lower extremity vessels in 23 patients. Although there were significant differences between the mean pressures in those patients who had proximal or distal arterial reconstruction, the mean pressure did not increase in the sequential preocclusion, occlusion, and postoperative periods during a mean follow-up of 26 hours in proximal reconstructions and 19 hours in distal reconstructions. One patient had pressures consistent with a borderline compartmental syndrome but died of a ruptured left ventricle before complete correlation of the clinical course and pressures could be made. We conclude from this study that although routine measurement of compartmental pressures during arterial reconstruction of the lower extremities yields interesting findings, it makes no important contribution to the clinical management of the patient.     

Fasciotomy after trauma to the extremities

Over a 9-year period, fasciotomy for presumed compartmental syndromes after trauma was performed in 25 upper extremities and 100 lower extremities in 122 patients. This procedure was most commonly indicated after vascular injuries in the lower extremities. Twenty percent of patients underwent fasciotomy before vascular repair. Nineteen percent of patients with vascular injuries in the lower extremities had fasciotomies performed at reoperation. Seventy-five percent of amputations in the lower extremities were related to a delay in performing fasciotomy or an incomplete fasciotomy. Upper-extremity fasciotomies most commonly did not decompress the deep component of the volar compartment, whereas lower extremity fasciotomies without fibulectomy most commonly decompressed all four below-knee compartments. Fasciotomy sites were closed by direct suture in more than half of the patients.     

Anatomic location of penetrating lower-extremity trauma predicts compartment syndrome development

Background

Compartment syndrome of the lower extremity can be a difficult diagnosis to make with serious consequences if diagnosis and intervention is delayed. Identifying patients who are more likely to develop this syndrome can help prevent the associated complications. The purpose of this study was to evaluate whether the anatomic location of the penetrating lower-extremity injuries can predict development of compartment syndrome.

Methods

A retrospective chart review was performed of all patients admitted for a minimum of 23 hours to the University of South Alabama trauma center for penetrating lower-extremity trauma during the 8-year period from July 1998 through June 2006. Patients were entered in the study if wound trajectory was confined to the lower extremity between the inguinal ligament and the ankle. Injuries were categorized as above knee (AK) or below knee (BK), and whether the injury was in the proximal or distal half of the extremity segment. Clinical examination or compartmental pressures were used to diagnose BK compartment syndrome.

Results

A total of 321 patients sustained 393 lower-extremity injuries during the study period, of which 255 (65%) were AK and 138 (35%) were BK. Thirty-one (8%) lower extremities developed BK compartment syndrome with 29 (94%) secondary to penetrating injuries of the BK segment. All BK injuries that developed compartment syndrome were located in the proximal half of the BK segment. Eighteen (7%) AK injuries underwent BK 4-compartment fasciotomy, 16 (6%) of which were prophylactic after surgical intervention for AK vascular injury. Two patients (1%) developed postoperative BK compartment syndrome after superficial femoral vein ligation. All AK injuries that underwent fasciotomy sustained vascular injuries requiring surgical intervention. No BK compartment syndromes occurred in any patients with expectantly managed AK or distal BK injuries.

Conclusions

Injuries to the proximal half of the BK segment are the most common cause for the development of compartment syndrome from penetrating injuries of the lower extremity. Development of BK compartment syndrome because of penetrating AK injury is rare without an associated surgically significant vascular injury. Observational admission for compartment syndrome development in patients with penetrating injury to the AK segment or distal BK segment is unnecessary.     

The surgical treatment of exertional compartment syndrome in athletes

We studied the cases of twelve patients who had bilateral exertional compartment syndrome involving one or all of the compartments of the lower extremities. The patients were divided into three groups based on the clinical findings. Group I consisted of seven patients with symptoms involving the anterior or lateral compartments only; Group II, of three patients with involvement of the deep posterior compartments alone; and Group III, of two patients with involvement of both the anterior and deep posterior compartments. On the basis of their clinical signs and symptoms each patient underwent dynamic tissue-pressure measurements using a slit catheter before, during, and for as long as thirty minutes after exercise. All patients had elevated resting and peak-to-peak dynamic pressure measurements. Treatment consisted of bilateral compartmental fasciotomy, as indicated. All of the patients in Group I had complete relief of symptoms; however, one patient in Group II and one in Group III had a recurrence of symptoms in the deep posterior compartment.     

Adjusting body weight for edema in severely burned patients

Weight loss is difficult to quantify in critically ill burn patients, as the presence of edema can mask changes in dry body weight. We sought to estimate dry body weight using measured weights adjusted for reported extremity edema. We evaluated patients with at least 20% total body surface area (TBSA) burns admitted to our intensive care unit over a 3½-year period. Body weights were collected for this analysis from admission to the time of a recorded dry weight after wound healing. Extremity edema was collected at the time of each weight measurement and was categorized into three groups: (1) no edema, (2) 1 + pitting edema, (3) 2 + or 3 + pitting edema. Logistic regression yielded the following formula for estimating dry weight (in kg): 0.66 x measured body weight + 25 – (3 for 1 + pitting edema or 4 for 2 + or 3 + pitting edema of either upper extremity) – (4 for any pitting edema to either lower extremity) (p < 0.01, R² = 0.81). These results may allow us to better estimate dry body weight changes in our edematous patients with severe burns. Nutrition goals can be adjusted earlier, when appropriate, based on these estimated dry body weight changes.     

Noninvasive measurement of compartment syndrome

This study compared the effectiveness of a commercially available invasive intracompartmental pressure measuring device with an investigational noninvasive hardness measuring device in 75 patients undergoing examination for possible compartment syndrome. Legs, forearms, thighs, and arms were tested. Pressure values and hardness ratios were compared to one another as continuous variables and to the clinical diagnosis of compartment syndrome as discrete variables. The compartment with the highest pressure reading within a limb diagnosed with compartment syndrome was compared to limbs without compartment syndrome. Due to the low specificity of the noninvasive measurement of hardness compared to the invasive pressure measurement (0.82 versus 0.96), this study does not support the use of the hardness monitor in the diagnosis of compartment syndrome.     

Acute intra-abdominal hypertension and "abdominal compartment syndrome"

The acute intra-abdominal hypertension causes profound physiologic abnormalities, both within and outside the abdomen. Just as in compartment syndrome in the extremities, gut mucosal ischemia begins long before clinical signs are evident, explaining the name of "abdominal compartment syndrome" given to the acute, markedly increased intra-abdominal pressure. The abdominal compartment syndrome was initially described in patients with severe abdominal injuries and massive transfusions and crystalloid infusions, caused by the closure of fascia or skin under tension, the use of bulky abdominal packs to control diffuse bleeding, the massive bowel distension and edema, and the continued bleeding into the abdominal cavity. Intra-abdominal pressure can be monitored by measuring the urinary bladder pressure with a manometer, connected to the transurethral Foley catheter, with the symphysis pubis as the zero point. A persistent elevation of the intra-abdominal pressure beyond 20-25 cmH2O, with significant respiratory, hemodynamic and renal dysfunction is an indication for abdominal decompression, before the manifestations of abdominal compartment syndrome became clinically evident. The mortality in patients with abdominal compartment syndrome is over 40%, even when adequately treated.     

Baseline compartment pressure measurements in isolated lower extremity fractures without clinical compartment syndrome

BACKGROUND: The diagnosis of compartment syndrome is most commonly made by clinical examination. Direct compartmental measurements generally serve an adjunctive role in establishing the diagnosis, except when patients have an alteration in mental status. There is little known on what are the expected baseline elevations in compartments after the simple occurrence of a fracture when clinical compartment syndrome does not exist. Knowledge of such measurements might influence the utility of pressure measurements in diagnosing compartment syndrome. METHODS: A prospective analysis of compartment measurements was performed in 19 isolated lower extremity fractures with the opposite leg as the control. The patients had no clinical evidence of compartment syndrome, had no alteration in mental status, and underwent planned surgical treatment within 48 hours of injury. RESULTS: Average compartment measurements were 35.5 +/- 13.6 mm Hg (range 10 to 62 mm Hg) in the injured leg versus 16.6 +/- 7.5 mm Hg (range 3 to 40 mm Hg) in the control leg (p = 0.0001). Eighteen patients (95%) had at least one compartment measurement that exceeded a single threshold of 30 mm Hg and 12 patients (63%) exceeded a threshold of 45 mm Hg. Eleven patients (58%) had at least one compartment reading within 20 mm Hg of their diastolic pressure and 16 patients (84%) had one within 30 mm Hg of their diastolic pressure. Ten patients (53%) had a reading within 40 mm Hg of their mean arterial pressure (delta P) and eight patients (42%) had a reading within 30 mm Hg of the mean arterial pressure. No patient developed sequelae or required surgery related to an unrecognized compartment syndrome during a minimum 1-year follow-up. CONCLUSIONS: Based on our data, use of direct compartment measurements with existing thresholds and formulations to determine the diagnosis of compartment syndrome may not accurately reflect a true existence of the syndrome. A search for other quantitative measures to more accurately reflect the presence of compartment syndrome is warranted.     

Compartment syndrome in all four extremities: a rare case associated with systemic capillary leak syndrome

While isolated limb injuries often lead to suspicion for and treatment of compartment syndrome, multi-limb compartment syndrome induced by a systemic disease is a rare entity, in which lack of immediate diagnosis can have catastrophic consequences to the patient. We present a patient with idiopathic systemic capillary leak syndrome (SCLS) resulting in compartment syndrome in all four extremities. Treatment required bilateral hand, forearm, calf, and thigh fasciotomies. Presenting symptoms included pain in all four extremities, malaise, and confusion. Laboratory data included polycythemia, hypoalbuminemia, leukocytosis, and elevated creatinine, but not a monoclonal spike on serum electrophoresis as is common in SCLS. Thus, when faced with clinical evidence of multiple extremity compartment syndrome, the surgeon should consider systemic disorders, such as SCLS, and aggressively treat the compartment syndrome as well as the underlying disease.     

Computed tomography angiography and magnetic resonance imaging performance of acute segmental single compartment syndrome following an Achilles tendon repair: A case report and literature review

Acute compartment syndrome of the lower extremity is a serious postinjury complication that requires emergency treatment. Early diagnosis is of paramount importance for a good outcome. Four muscle compartments in the calf (anterior, lateral, deep posterior, and superficial posterior) may be individually or collectively affected. Acute segmental single-compartment syndrome is an extremely rare condition characterized by high pressure in a single compartment space with threatening of the segmental tissue viability. In this case report, we describe a young man with Achilles tendon rupture who complained of postoperative pain in the anterior tibial region. Emergent computed tomography angiography and magnetic resonance imaging revealed local muscle edema. Segmental anterior compartment syndrome was diagnosed and fasciotomy was performed.     

Compartmental syndrome and its relation to the crush syndrome: A spectrum of disease. A review of 11 cases of prolonged limb compression.

A review of 11 cases of prolonged limb compression usually following drug overdose, revealed a spectrum of disease from isolated compartmental syndromes to full crush syndromes with renal failure. Residual limb contractures were moderate or severe in 80 per cent of the extremities involved. Five of the 11 patients demonstrated significant, systematic manifestations, Stage II or Stage III crush syndrome by our definition. The severity of the systemic manifestations is related to the amount of muscle tissue being subjected to elevated pressure and the length of time this pressure is maintained. Delay in hospitalization, delay in diagnosis, and delay in treatment prolong this period. The diagnosis should be made on the basis of the histroy of prolonged immobilization and the finding of a swollen extremity. Fasciotomy should be performed immediately, both to minimize residual limb contracture and to prevent the crush syndrome from developing secondary to myonecrosis.