Compartment syndrome: Challenges and solutions

Abstract

Compartment syndrome is defined as increased pressure within a fibro-osseous space resulting in decreased tissue perfusion to structures within that space. Hence, early identification is critical for successful outcomes. There are two types of compartment syndrome - acute and chronic. Out of the two, acute compartment syndrome (ACS) is more worrying and needs urgent attention. ACS can be caused by a number of factors. These can be broadly classified as factors causing increased volume within a closed space, or those that restrict the compartment from expanding. The mainstay of diagnosis is a high index of clinical suspicion particularly in high risk cases. The three main findings that point toward compartment syndrome which clinicians rely on are 1) pain out of proportion to expectation, 2) stretch pain, ie, pain exacerbated by passive movement/stretch of muscles within the compartment, and 3) tense swelling. Though there are no reproducible and reliable tests for compartment syndrome, measurement of intracompartmental syndrome is required in cases where diagnosis is unclear. Traditionally a measurement of 30 mmHg was taken as a cut off value above which fasciotomy was necessary. A delta pressure of 30 mmHg or less can also be used to indicate the need for fasciotomy. Delta pressure, is the difference between the diastolic blood pressure of a patient and the pressure of the compartment measured (∆P = diastolic pressure - intracompartmental pressure). In terms of management, removal of any constrictive dressings is a critical step to allow accurate assessment of the limb. If there is a doubt then the diagnosis of ACS should be considered unless proven otherwise. Once the diagnosis is made, the treatment is surgical in the form of fasciotomy. The aim is to decompress the involved compartments. The suggestion however, is to decompress all compartments of the affected part of the limb. Compartment syndrome is a serious condition and every care must be taken to treat this condition as soon as possible.