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. 

Acute and chronic are the two primary categories.The most common areas affected are the arm or leg.

Compartments are spaces where muscles or organ groups are arranged. The walls of these compartments are composed of robust fascia, which are webs of connective tissue.

Blood or edema may collect in the compartment following an injury. Fascia's strong walls make it difficult for them to expand, which causes compartment pressure to rise and insufficient blood flow to the tissues inside the compartment. There may be severe tissue damage, loss of bodily function, or even death.

CAUSES OF COMPARTMENT SYNDROME

The most prevalent kind of compartment syndrome is acute compartment syndrome. About 3% of patients with a forearm mid-shaft fracture develop acute compartment syndrome.

The fracture itself may cause compartment syndrome because of the pressure from edema and bleeding. Alternatively, compartment syndrome could develop later as a result of POP and surgery used to treat the fracture.

Injuries other than fractures of the bones can also result in acute compartment syndrome, such as:

• 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.

SIGNS & SYMPTOMS OF COMPARTMENT SYNDROME

Acute Compartment Syndrome:

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.

                 

• Swelling, tightness and bruising.

                                                                                                     swelling

Chronic Compartment Syndrome:

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

In addition to the standard symptoms and indicators, intra-compartmental pressure measurement is critical for diagnosis. Five centimeters into the injury area is where a transducer attached to a catheter is inserted.When a conscious or unconscious person experiences a pressure greater than 30 mmHg of their diastolic pressure, compartment syndrome is suspected, and fasciotomy is recommended. Compartmental syndrome is linked to a pressure that is 20 mmHg greater than the intra-compartmental pressure in patients with hypotension.

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

TREATMENT - MANAGEMENT

Medical Management:

• Fasciotomy is the gold standard of care, however the majority of studies on its efficacy have short follow-up durations.It is advised that one lateral incision, or anterolateral and posteromedial incisions, be used to decompress the four compartments (anterior, lateral, deep posterior, and superficial posterior).
• 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.

Physiotherapy Management:

Stopping the causing activities is the only non-surgical treatment that can be guaranteed to reduce the pain associated with CECS. Whenever possible, one should alter their regular physical activities.

For patients who want to keep up their cardiorespiratory fitness, cycling may be a better option than running because it has a lower risk of raising compartment pressure. For patients with mild symptoms or those who choose not to have surgery, massage therapy may be beneficial. 

Treatment alone won't make the symptoms go away, though, as nonoperative methods have generally proven ineffective. Untreated compartment syndrome has been linked to ischemia of the muscles and nerves, which can result in irreversible damage such as muscle necrosis, tissue death, 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.

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.

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.