5. Discussion
Compartment syndrome is caused by an increase in intracompartmental pressure within a confined space, causing oxygen deprivation and resulting in cell damage.2 Early identification of compartment syndrome is critical to avoid amputation or even death.3 Compartment syndrome is most commonly seen in the forearm or lower leg after a traumatic, high-impact injury.2
Compartments are made up of a group of tissues and their associated nerves and vessels, covered and contained by a fascia.4 The fascia is not elastic and therefore does not allow for an increase in the compartment volume or pressure.3 Compartment syndrome occurs when the pressure in one of these compartments increases greatly as a result of swelling and/or hemorrhage.3 This usually occurs after a traumatic injury, but can also be associated with surgery, compressive bandages, casts, fractures, burns, snake or spider bites, crush injuries or electrical injuries.2,4,5
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An increase in compartment pressure leads to vessel collapse, causing decreased blood flow to the cells in the area. If not addressed quickly, ischemia can occur, leading to more edema and cell death.6 Eventually, if not treated, necrosis will occur resulting in rhabdomyolysis. In severe cases, this can lead to renal failure, multi-organ failure and death.6
Diagnosing compartment syndrome is based on a careful history, a through physical exam, and a high index of suspicion due to the mechanism of injury.5 The most common symptom of acute compartment syndrome (ACS) is severe pain that is out of proportion to the clinical picture.4
Patients with compartment syndrome also generally have pain with passive extension of the muscle compartment, altered sensation, muscle weakness and tense, tender compartments.5 Several techniques can measure the intracompartmental pressure. The two most widely used are invasive devices: the slit-catheter and the side-port needle.2
Prompt treatment is necessary to avoid contractures, amputation, multi-organ failure and possible death.5 Nonsurgical treatments include immediate removal of casts, compressive dressings, tourniquets or splints.6 The affected extremity should be elevated to heart level, but no higher, to ensure maximum perfusion while decreasing swelling.2
Immediate fasciotomy is the standard treatment for ACS.2 The goal is to decompress the affected compartments before muscle necrosis.2 In the forearm, fasciotomies are performed on both the dorsal and volar aspects with extension into the carpal tunnel.2
Compartment syndrome can be devastating if not treated quickly and correctly. It is usually the result of high-impact trauma. The most important factors in diagnosing compartment syndrome in a patient are a thorough physical exam and detailed history, coupled with a high degree of suspicion. Decompression with fasciotomy is the definitive way to ensure a satisfactory outcome.
Lindsey Barkson, MSN, FNP-BC, is a family nurse practitioner specializing in hand and orthopedic trauma at Riverside Methodist Hospital in Columbus, Ohio.
References
1. Favaloro, EJ, Wong RW. Laboratory testing for the antiphospholipid syndrome: making sense of antiphospholipid antibody assays. Clin Chem Lab Med. 2011;49:447-461.
2. Konstantakos EK, Dalstrom DJ, Nelles ME, et al. Diagnosis and management of extremity compartment syndrome: An orthopaedic perspective. Am Surg. 2007;73:1199-1209.
3. Wright E. Neurovascular impairment and compartment syndrome. Paediatr Nurs. 2009;21:26-29.
4. Bucholz RW, Court-Brown CM, Heckman JD, Tornetta III P. Rockwood and Green’s Fractures in Adults: Vol. 1, 7th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2010:689-703.
5. Malik AA, Khan WS, Chaudhry A, et al. Acute compartment syndrome — a life and limb threatening surgical emergency. J Perioper Pract. 2009;19:137-142.
6. Burkhart KJ, Mueller LP, Prommersberger KJ, Rommens PM. Acute compartment syndrome of the upper extremity. Eur J Trau Emer Surg. 2007;33:584-588.
