Compartment syndrome is a condition in which increased pressure within a closed space compromises the circulation of the tissue contained within that space. This condition can affect any compartment in the body, but it most often involves the lower leg. Almost any injury can cause this syndrome including injury resulting from vigorous exercise. However, the most common causes of compartment syndrome are fractures and soft tissue injuries.
It usually occurs in the lower leg as a result of a tibial fracture, especially a high energy fracture (Figure 1). Edema hemorrhage causes fluid accumulation, elevating the intracompartmental pressure and occlusion of blood vessels. Ischemia and interference with microcirculation of the muscles and nerves will occur, which results in clinical findings of compartment syndrome.
The clinical findings of compartment syndrome include pain more than expected from the injury, tense swelling, and pain with passive stretch of the compartment.
Sometimes the intracompartmental pressure is measured (Figure 2). An absolute pressure of 30 mm Hg or higher or within 30 mm Hg of the diastolic blood pressure is considered diagnostic of acute compartment syndrome. Without urgent decompression tissue ischemia, necrosis and functional impairment will occur. A fasciotomy should be done as soon as the condition is diagnosed or suspected, with or without measuring the pressure. A delay in the treatment of more than six hours can cause permanent damage to the muscles and nerves, leaving a major disability.
Anatomy is crucial in the treatment of compartment syndrome. The four compartments of the leg include the anterior, lateral, superficial posterior, and deep posterior (Figure 3).
Fasciotomy is the treatment of choice for compartment syndrome. A complete decompression of the lower leg is accomplished through a double incision. The first incision is placed halfway between the fibular shaft and the tibial crest. The fasciae anterior and posterior to the septum are opened transversely. The anterior compartment is released first, followed by the release of the lateral compartment (Figure 4). Care should be taken not to injure the superficial peroneal nerve, located within the lateral compartment.
The second incision is made medial to the previous incision, 2 cm posterior to the posterior tibial margin. Care should be taken not to injure the saphenous nerve and vein. The fasciae anterior and posterior to the septum are opened transversely. The superficial posterior compartment is released first, followed by the release of the deep posterior compartment (Figure 5).
Recently a single incision is described by the author. The procedure is usually done in the operating room. However, it can be done in the emergency room, on the floor, or in the intensive care unit, if necessary. A bedside fasciotomy may be necessary to save the limbs and is proposed by the author. Time is critical to release the pressure and ensure adequate circulation of the extremity.
Chronic exertional compartment syndrome is an exercise induced condition, different from acute compartment syndrome. In patients with chronic exertional compartment syndrome, the resting intracompartmental pressure is usually greater than 15 mm Hg. Pressure rises steeply after the initiation of exercise, usually culminating in pain within 20 minutes. Burning, cramping or aching pain and tightness develop, leading to a cessation of activity. An intracompartmental pressure that remains over 30 mm Hg one minute after the end of exercise or pressure and/or that remains over 20 mm Hg for longer than 5 minutes after the end of exercise is considered diagnostic of chronic exertional compartment syndrome (Figure 6). While initial treatment is conservative, a fasciotomy is the only proven successful treatment.
For more information on compartment syndrome, follow the links below:
Publications on Compartment Syndrome
Ebraheim, Nabil A., Saaid Siddiqui, and Craig Raberding. "A Single-Incision Fasciotomy for Compartment Syndrome of the Lower Leg." Journal of Orthopaedic Trauma 30.7 (2016): e252-e255. PMID: 27333459
Ebraheim, Nabil A., et al. "Bedside fasciotomy under local anesthesia for acute compartment syndrome: a feasible and reliable procedure in selected cases." Journal of Orthopaedics and Traumatology 13.3 (2012): 153-157. PMID: 22527150
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