Compartment syndrome

Compartment syndrome is a condition caused by increased pressure inside a muscle compartment. If left untreated, compartment syndrome results in permanent death of the muscles of the involved compartment.

Glossary

A syndrome is "a set of symptoms that occur together."

The label compartment syndrome refers to a very specific problem related to increased pressures inside a muscle compartment.

The entity known as "acute compartment syndrome" is a true medical emergency. Once diagnosed, it is imperative that fasciotomy be performed as soon as possible.

Why does this happen?

Compartment syndrome occurs most commonly after traumatic injuries, usually in the leg.

After trauma, bleeding inside a tight fascia compartment causes the pressure to increase. If the pressure rises past a certain threshold, blood flow into the compartment becomes compromised. Once hydrostatic pressure inside the compartment becomes higher than the blood pressure, blood cannot flow into, and cannot supply the compartment with nutrients. The muscle then suffers, becomes edematous, and the pressures increase further. This vicious circle ultimately results in permanent death of the muscle.

Signs and symptoms of compartment syndrome

  1. Pain
  2. Pallor
  3. Pulselessness
  4. Paresthesias
  5. Paralysis

However, the most important sign of compartment syndrome is pain. The other signs develop later, sometimes too late. Treatment should not be delayed because the pulse is easy to feel. It is possible to have irreversible muscle damage, yet have an easily palpable pulse.

How is compartment syndrome diagnosed?

As a physician, the main way I diagnose compartment syndrome is by "obtaining a history" and by examining the patient.

In certain situtations, compartment pressures may be measured with a needle connected to a pressure transducer. This is important in patients who are not conscious, for instance.

How is compartment syndrome treated?

Fasciotomy is effective when the problem is diagnosed on time. The operation consists of cutting of the tight muscle covering layer (fascia). This allows the muscle to expand: the pressure then drops, the muscle gets perfused with blood and it does not die.

Is it possible to get compartment syndrome without a broken bone?

The answer is a definitive "yes."

One case that I remember was that of a young man who had overdosed with heroin. When he lost consciousness, he lay with his leg positioned on the wooden side of a fouton. He regained consciousness with severe leg pain. I diagnosed him with compartment syndrome, performed fasciotomy, and he recovered without muscle damage.

In another instance, a patient using coumadin, which is a powerful blood thinner, bumped her thigh slightly on a table. That was enough to cause bleeding inside her thigh quadriceps muscle. She then developed severe thigh pain pain. She indicated this was "the worst pain ever." I performed fasciotomy of her anterior thigh compartment, followed by full recovery.

The most memorable case is that of a young athletic man, very driven, who was "pacing." At some point he felt a searing snap inside his thigh. He did not stop and rest, but he continued running until he could not. What he had done was to tear a few muscle fibers together with small artery in his quadriceps muscle. If he had stopped running at that point, he would probably have felt a few more cramps but would have eventually healed without medical intervention. Instead, he continued to run and made his bleeding worse. Eventually he was brought to the ER with a swollen painful thigh, unable to walk due to severe pain. He underwent emergency fasciotomy, during which I found and ligated a bleeding deep femoral artery branch. The young man recovered fully because fasciotomy was performed in a timely manner. (If you are reading this, you know who you are.)

What is fasciotomy?

Fascia is the tight inelastic layer that covers a muscle. Fasciotomy is an operation where the fascia of the muscle is divided lengthwise to allow the muscle fibers to expand.

After fasciotomy is done, the wound remains open and meticulous wound care is necessary to prevent infection. In these situations, wound care most commonly is performed in the OR, under general anesthesia, 2-3 times per week. A wound VAC is often part of the treatment.