Compartment Syndrome
The reason for compartment syndrome is the excessive build up of pressure in one of the tissue compartments of the limbs, stopping the arterial pressure from supplying the area and depriving the tissues of adequate blood supply. Death of the local tissues with significant pain can occur if treatment is not promptly administered. The forearm and the lower leg are the most common sites for this to occur, in which areas the muscles are bounded by a semi-rigid compartment made up of firm connective tissue fascia and by bone. If the pressure builds up inside here its lack of extensibility can cause problems within the compartment.
Tibial fractures are the most common cause of compartment syndrome, other causes being compromise of the blood vessels, tight dressings or plasters, crush injuries and other fractures. Established compartment syndrome shows itself by a loss of sensation, loss of movement of the part and loss of pulses. Decompression of the tight compartment is the typical and most effective treatment for this syndrome. Complications include breakdown of muscle tissue which can progress to renal failure and Volkmann contracture, a non-reversible damage to the muscles of the forearm.
Acute onset of compartment syndrome is the most common presentation after a traumatic event, chronic compartment syndrome has been described secondary to excessive exercise by measuring the pressure occurring within the leg compartments. Inside the compartment composed of the muscle and fascia the pressure rises, steadily reducing the blood flow into the area until muscle and nerve damage occurs. Acute compartment syndrome comes on quickly with the irreversible damage following closely after unless it is treated promptly.
Chronic compartment syndrome is not dissimilar from shin splints and occurs in athletes, often bilaterally and after a specific time of exercising. There are various criteria for this condition in different activities and the intra-compartmental pressure can now be measured to look for abnormalities. The highest incidence of compartment syndrome occurs in patients with open tibial fractures and much less commonly in closed tibial fractures. Compartment syndrome can also occur along with vascular injuries but decompression may be routinely performed at the time of vascular repair.
For compartment syndrome to occur there must be either external or internal reasons for a raised pressure in the segments of the limb. External forces can include over tight clothes or boots and tight dressings or plasters. Internal factors can be numerous and include tissue swelling due to crush injury, fractures or internal tissue bleeding and even overdoing weightlifting. The muscles and the nerves are starved of blood due to the excessive pressure, causing chemical changes due to muscle necrosis which attract greater amounts of water into the compartment, increasing the pressure again. Eventually arterial blood flow is completely obstructed.
The elevation of pressure in the leg compartments needs decompression to be performed quickly or with a delay of six or ten hours there will be widespread tissue and muscle death and significant nerve damage. When muscles suffer damage this results in the release of myoglobin into the bloodstream which can engender renal damage which can be fatal. During exercise there is a volume increase in the muscles, raising the compartment pressures during the chronic type of this condition, keeping the levels high between muscle action and compromising blood flow. Muscle cramps can then occur as they do not get enough blood.
Diagnosis of acute lack of blood to a limb can be indicated by limb pallor, pulse loss, pins and needles, pain and coldness of the leg, however these signs are not reliable in terms of diagnosis in clinical practice. Presentation may be of unexpectedly elevated levels of pain not seemingly related to the injury level, with an aching, deep pain which is worse on muscle stretching. On examination of the limb it should be clear whether there is any likelihood of internal tissue damage. Sensory testing can be helpful as pressure shows more obviously in sensory nerve function.
Fasciotomy is the definitive surgical treatment for compartment syndrome, a cutting into the individual muscle compartments to allow the pressure to dissipate outwards and decompress the areas. The wounds may be left open for some days until the pressure subsides and the tissues recover.
Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in bradford visit his website.
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