Acute compartment syndrome of the extremity: Rapid overview of emergency management

ACS occurs when the pressure in a muscle compartment rises sufficiently to cause tissue ischemia leading to muscle or nerve damage. Impending ACS occurs when tissue pressure has begun to increase and tissue perfusion is reduced but is not sufficient to cause muscle or nerve damage.

Risk factors

Severe trauma: Long bone fracture, crush injury.

Prolonged extremity ischemia with reperfusion.

Spontaneous bleeding, hematoma.

Burn injury, massive fluid resuscitation, SIRS.

Others:* Myositis, myonecrosis, rhabdomyolysis, prolonged immobilization, bites and stings, high pressure injection, intravenous extravasation injury, soft tissue infection, intra-arterial injection, birth injury.

Clinical features

Physical examination alone has limited sensitivity and specificity for ACS. Serial examinations are important in patients at risk. Clinical features include:

Significant extremity pain is the primary feature; pain can be "out of proportion" to apparent injury.

Pain and other features can progress rapidly over a few hours.

Tense, firm compartment (note: deep posterior compartment of the leg cannot be palpated).

Pain exacerbated by passive stretch of muscle within the compartment.

Compartment-specific neurovascular findings (eg, paresthesias, reduced sensation, muscle weakness, diminished pulses).^¶

Other clinical findings that suggest impending ACS include:

Excessive or disproportionate increase in extremity girth.

Acidosis or hyperkalemia following reperfusion.

Clinical evidence of rhabdomyolysis (eg, high CK >30,000 units).

Initial measures and reassessment

Normalize extremity perfusion (eg, fluid resuscitation, align fractures).

Relieve external pressure on the compartment (eg, bivalve or remove cast, escharotomy for circumferential burns).

Measure compartment pressures

Whenever possible, pressure measurements should be obtained by the surgeon who will perform fasciotomy.

Compartment pressures typically measured with handheld manometer.

Needle (eg, 18 gauge) attached to a pressure transducer (eg, arterial line setup) can be used.

Fasciotomy

Extremity fasciotomy is the only recognized treatment. Early fasciotomy (ideally within four hours of symptom onset) can save the extremity.

Indications:^Δ

High clinical suspicion.
Compartment pressure within 30 mmHg of diastolic pressure.

Contraindications: Established late compartment syndrome is not likely to benefit from fasciotomy. Tissue damage becomes irreversible 4 to 8 hours after compartment pressure has increased. Fasciotomy for established ACS after 6 hours of onset increases the rate of infection and amputation.

Techniques:

Leg: A four-compartment fasciotomy is recommended using either a one- or two-incision approach.
Forearm: One or two incisions are made on the volar surface and one on the dorsal surface.
Fasciotomies of the buttock, thigh, shoulder, upper arm, or hand are needed less often.

Observation

Patients in whom clinical suspicion is not high.

Hourly reassessment for clinical features of ACS.

Repeat compartment pressures, as needed.

This table is intended for use in conjunction with additional UpToDate content on extremity compartment syndrome. Refer to UpToDate topics on classification and causes, clinical features and diagnosis, and techniques to perform fasciotomy.

ACS: acute compartment syndrome; SIRS: systemic inflammatory response syndrome; CK: creatine kinase.

* Less common risk factors include nontraumatic muscle injury, severe deep vein thrombosis, soft tissue infection, extravasation injury, intra-arterial injection, and systemic inflammatory response syndrome.

¶ Reduced sensation, motor weakness, and diminished pulses are late findings.

Δ Prophylactic fasciotomy may be performed for patients at high risk for ACS but without symptoms.

Graphic 114715 Version 3.0

خرید پکیج

Acute compartment syndrome of the extremity: Rapid overview of emergency management