An acute extremity compartment syndrome is a serious and sometimes catastrophic entity that can lead to irreversible local and systemic damage.1 It is initiated by a variety of injuries and characterized by a cycle of edema and ischemia. A compartment syndrome is a condition involving increased interstitial pressure in a closed and confined space that results in inadequate perfusion and impaired tissue function.2 The muscles, nerves, and vasculature within the affected muscle group can all be compromised by the edema and prolonged ischemic state with the potential for significant morbidity.
A compartment syndrome may lead to loss of muscle or nerve function, ischemic contractures, rhabdomyolysis, infection, and amputation. This can be followed by systemic complications (e.g., renal failure, sepsis, and possibly death).3 Ischemic contractures of the extremities were first described over 100 years ago by Richard Von Volkmann and are now referred to as “Volkmann’s ischemic contractures.” Common causes of a compartment syndrome include anticoagulation, circumferential burns, constrictive dressings (e.g., tight-fitting bandages, casts, or splints), crush injuries, electrical injuries, exercise, external trauma to the extremity, extravasation (e.g., contrast or misplaced injections), joint dislocations, open or closed fractures, reperfusion after a vascular insult, and snakebites (Table 93-1).1-27 Fractures are the most common etiology of a compartment syndrome.4,23 Rare causes include unusual circumstances or spontaneous compartment syndrome.28,29
The difficulty in diagnosing a compartment syndrome is that the physical examination is a poor indicator of the degree of microcirculatory compromise.5,29,30,31 Common symptoms historically associated with a compartment syndrome have been shown to be unreliable to diagnose and identify a compartment syndrome, and the diagnosis requires a high level of clinical suspicion on the part of the Emergency Physician.2,6-8 Refer to Chapter 93 for the complete details of a compartment syndrome.
Treatment of a compartment syndrome with a fasciotomy was first suggested in 1906 by Bardenheuer.9 Maintaining a low threshold for performing a fasciotomy can be the safest course for the patient. The prognosis is more favorable if a fasciotomy is performed soon after the onset of symptoms.10 There may be little or no benefit to performing a fasciotomy if it is delayed. A basic knowledge of the anatomy of commonly affected compartments is necessary to safely and successfully perform an extremity fasciotomy.
ANATOMY AND PATHOPHYSIOLOGY
The specific anatomic site of an extremity compartment syndrome is variable, as it can occur in any muscle tissue that is confined in a space by fascia, skin, or any external forces (e.g., casting material). Compartmental perfusion is a dynamic process maintained by arterial blood pressure and limited by the absolute compartment pressure. Increased intracompartmental pressure from edema or hemorrhage within or from external compression of the compartment compromises arterial perfusion, causes venous outflow obstruction, and eventually leads to tissue ...