COMPARTMENT SYNDROME

DESCRIPTION

Compartment syndrome is a condition in which increased pressure within one of the body’s compartments results in insufficient blood supply to tissue within that space.Compartment syndrome usually results from bleeding or swelling after an injury. There are two main types: acute and chronic.The leg or arm is most commonly involved.
Groups of organs or muscles are organized into areas called compartments. Strong webs of connective tissue called fascia form the walls of these compartments.After an injury, blood or edema may accumulate in the compartment. The tough walls of fascia cannot easily expand, and compartment pressure rises, preventing adequate blood flow to tissues inside the compartment. Severe tissue damage can result, with loss of body function or even death.

CAUSES

Acute compartment syndrome is the most common type of compartment syndrome. Acute compartment syndrome occurs in about 3% of those who have a mid-shaft fracture of the forearm.Compartment syndrome can develop from the fracture itself, due to pressure from bleeding and edema. Or compartment syndrome may occur later, as a result of treatment for the fracture such as surgery and POP.
Acute compartment syndrome can also occur after injuries without bone fractures, including:

  • Crush injuries
  • Burns
  • Overly tight bandaging
  • Prolonged compression of a limb during a period of unconsciousness
  • Surgery to blood vessels of an arm or leg
  • A blood clot in a blood vessel in an arm or leg
  • Extremely vigorous exercise, especially eccentric movements (extension under pressure)
  • vigorous exercise.
    Acute Compartment Syndrome with blister formation

SIGNS & SYMPTOMS

Acute

There are five characteristic signs and symptoms related to acute compartment syndrome: pain, paraesthesia (reduced sensation), pallor, and pulselessness. Pain and paresthesia are the early symptoms of compartment syndrome.

  • Pain – The pain would be disproportionate to the findings of the physical examination, is not relieved by analgesia up to and including morphine. The pain is aggravated by passively stretching the muscle group within the compartment. However, such pain may disappear in the late stages of the compartment syndrome.The role of local anaesthesia in delaying the diagnosis of compartment is still being debated.
  • Paresthesia (altered sensation) – A person may complained of “pins & needles”, numbness, and tingling sensation. This may progress to loss of sensation (anesthesia) if no intervention has been made.
  • Paralysis – Paralysis of the limb is a rare, late finding. It may indicate both nerve or muscular lesion.
  • Pallor and pulselessness – A lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often well below arterial pressures. Absent pulses only occurs when there is arterial injury or during the late stages of the compartment syndrome.
pallor leg
  • Swelling, tightness and bruising.
                               swelling

Chronic

The symptoms of chronic exertional compartment syndrome (CECS) are brought on by exercise and consist of a sensation of extreme tightness in the affected muscles followed by a painful burning sensation if exercise is continued. After exercise is ceased, the pressure in the compartment will decrease within a few minutes, relieving painful symptoms. Symptoms will occur at a certain threshold of exercise which varies from person to person but is rather consistent for a given individual and can range anywhere from 30 seconds of running to about 10–15 minutes of running. CECS most commonly occurs in the lower leg, with the anterior compartment being the most frequently affected compartment.Foot drop is a common symptom of CECS.

DIFFERENTIAL DIAGNOSIS

Patients with exercise-induced lower leg pain, differential diagnosis includes:

  • medial tibial stress syndrome (MTSS)
  • fibular and tibial stress fractures
  • fascial defects
  • nerve entrapment syndromes,
  • vascular claudication
  • lumbar disc herniation.

DIAGNOSIS

Apart from the typical signs and symptoms, measurement of intra-compartmental pressure is also important for diagnosis. A transducer connected to a catheter is inserted 5 cm into the zone of injury.A pressure higher than 30 mmHg of the diastolic pressure in conscious or unconscious person is associated with compartment syndrome; and fasciotomy is indicated. For those with hypotension, a pressure of 20 mmHg higher than the intra-compartmental pressure is associated with compartmental syndrome.

measurement of itra compartment pressure

According to Blackman one of the tools to diagnose compartment syndrome is X-ray to show a tibia/fibula fracture, which when combined with numbness of the extremities is enough to confirm the presence of compartment syndrome.
Less invasive measurement techniques:

  1. Laser Doppler ultrasound
  2. Methoxy isobutyl isonitrile enhanced magnetic resonance imaging (MRI)
  3. Phosphate-nuclear magnetic resonance (NMR) spectroscopy

MANAGEMENT

Medical Management

  • The gold standard treatment is fasciotomy, but most of the reports on its effectiveness are in short follow-up periods.It is recommended that all four compartments (anterior, lateral, deep posterior and superficial posterior) should be decompressed by one lateral incision or anterolateral and posteromedial incisions.Surgery Patients may be able to participate in all common activities a few days post surgery.Treatment should begin with rest, ice, activity modification and if appropriate, nonsteroidal anti-inflammatory drugs.
                                    faciotomy

Physiotherapy Management

  • The only nonoperative treatment that is certain to alleviate the pain of CECS is the cessation of causative activities. Normal physical activities should be modified, pain allowing. Cycling may be substituted for running in patients who wish to maintain their cardiorespiratory fitness, as it is associated with a lower risk of compartment pressure elevation. Massage therapy may provide some benefit to patients with mild symptoms or to those who decline surgical intervention. Overall, however, nonoperative treatment has been generally unsuccessful and symptoms will not disappear without treatment. As alluded to, untreated compartment syndrome can cause ischemia of the muscles and nerves and can eventually lead to irreversible damage like tissue death, muscle necrosis and permanent neurological deficit within the compartment.
  • Aquatic exercises, such as running in water, can maintain/improve mobility and strength without unnecessarily loading the affected compartment. Massage and stretching exercises also have been shown to be effective.
      Aqua Jogging

 

Post-surgical management

Post-surgical therapy for CECS includes:

  • Assisted weight bearing exercise with variation,
  • Early mobilisation is recommended as soon as possible to minimise scarring, which can lead to adhesions and a recurrence of the syndrome.
  • Activity can be upgraded to stationary cycling and swimming after healing of the surgical wounds,
  • Isokinetic muscle strengthening exercises can begin at 3-4 weeks,
  • Running is added into the activity program at 3-6 weeks,
  • Full activity is introduced at approximately 6-12 weeks, with a focus on speed and agility.
Achilles-Tendon Stretching
TIBIALIS ANTERIOR STRETCHING

 

 

 

 

 

 

 

 

 

walking aid

 

            SHOE VARIATION

 

 

 

 

 

 

 

 

 

The following are recommendations for a full recovery and to avoid recurrence;

Wearing more appropriate footwear to the terrain
Choosing more appropriate surfaces and terrain for exercise
Pacing your activities
Avoiding certain activities altogether
Mastering strategies for recovery and maintenance of good health (e.g, appropriate rest between sessions)
Modifying the workplace to lower the risk of injury
Postoperative physical therapy is essential for a successful recovery. depending on the nature of the procedure, expected timelines for healing and progress made during rehabilitation. Treatment incorporates strategies to restore range of motion, mobility, strength and function.

 

 

 

 

 

 

 

 

 

 

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