Chapter 63

The ability to diagnose a compartment syndrome is a critical skill for the Emergency Physician. Early identification of a compartment syndrome can enable the appropriate treatment and may facilitate limb salvage. A compartment syndrome begins when an imbalance of volume and pressure within a myofascial compartment results in diminished blood flow.1 A compartment syndrome has been classically described in the early literature as a Volkmann ischemic contracture following vascular insufficiency in the forearm.3

A compartment syndrome can occur in almost any muscle group that is contained within a confined fascial space. Common locations include the leg, forearm, and gluteal area. There are many causes of a compartment syndrome. These include protracted muscle ischemia (secondary to necrosis from a contusion), swelling (secondary to volume overload states or a fracture), or a thrombus in a vessel that traverses the compartment. In the Emergency Department, a compartment syndrome is most commonly associated with long bone fractures or blunt trauma.2 Other etiologies for a compartment syndrome include complications from a coagulopathy, dialysis, surgery, or states of obtundation.4–6

Identifying a compartment syndrome in a timely fashion can be challenging. The hallmark symptom is persistent and progressive pain that is disproportionate to the underlying cause. The pain typically increases with passive motion. A catastrophic mistake is to attribute the etiology of the patient’s pain solely to the underlying problem, such as the fracture.7,8 Other signs and symptoms associated with a compartment syndrome occur late in the course and include paresthesias of the involved nerve, paralysis of the involved muscle group, pallor of the skin, and diminished pulses.9 Waiting for the development of all the clinical signs and symptoms is an invitation for permanent and dangerous sequelae, including muscle necrosis and possible loss of a limb. Measurement of elevated tissue pressure within the muscle compartment is currently the most common objective means of diagnosing this syndrome. The compartment pressure must be released by performing an emergent fasciotomy of the involved compartments once a compartment syndrome is identified.

The anatomy of a compartment syndrome is variable, as it can occur in any enclosed muscle group. Any muscle tissue that is confined in space by fascia, skin, or any external forces (e.g., casting material) is a potential site for the development of a compartment syndrome. The muscles, nerves, and vasculature within the affected muscle group are all potentially compromised by a prolonged ischemic state followed by swelling.

The initial imbalance of a compartment syndrome occurs between the volume and pressure within the myofascial compartment. The arterial inflow and venous outflow diminish as either intracompartmental volume or pressure increases. The blood begins to be shunted via capillaries into the muscle tissue. This compensatory shunting of blood further disturbs the volume-pressure balance, resulting in impaired tissue oxygenation.2,9,10

The extent of the tissue damage is determined by the duration of ischemia. ...

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