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BACKGROUND

Clinical Importance

Compartment syndrome is a condition in which increased pressure within a limited space compromises the circulation and function of affected tissues.1,2 Hippocrates may have been the first to describe the dangers of elevated intracompartmental pressures in 400 B.C. Vascular injury is a common cause, but there are many others.

Compartment syndrome is a limb- and potentially life-threatening condition, and surgeons who treat patients with injuries therefore require a thorough understanding of how to prevent and manage this condition. Failure to identify and treat compartment syndrome properly can lead to tissue necrosis, permanent functional impairment, amputation, acute kidney injury, and death.3 These sequelae are disappointingly common—in a 9-year review of extremity trauma, Feliciano and coworkers found that three-quarters of amputations in the lower extremity were related to a delay in performing a fasciotomy or an incomplete fasciotomy.4 Failure to diagnose or properly treat a compartment syndrome is also one of the most common causes of medical litigation.2 In nine cases settled between 1980 and 2003 in Massachusetts, the average indemnity payment was $426,000, with one award as high as $14.9 million.5

In contradistinction to its obvious clinical importance, training in how to perform a fasciotomy is problematic. The average number of fasciotomies reported in case logs submitted to the American Board of Surgery for 2011 graduates of U.S. surgical residencies was 1.2, and the average number of fasciotomies reported by graduates of U.S. vascular fellowships in the last decade has been between 0.8 and 1.4 per year. It appears that otherwise well-trained surgeons are ill-prepared to recognize and manage compartment syndrome and to perform a relatively straightforward procedure. The purpose of this chapter is to review the pathophysiology, diagnosis, relevant anatomy, and treatment of compartment syndrome, with an emphasis on the proper performance of fasciotomy of the lower leg and the complications associated with this vital limb and life-saving procedure.

Pathophysiology

Groups of muscles and their associated nerves and vessels are surrounded by fascial layers that define the compartments of the extremities. These compartments are of relatively fixed volume. Compartment syndrome occurs either when compartment size is restricted or compartment volume is increased. In the context of trauma, possible causes include venous hypertension from proximal injury or ligation, reperfusion after arterial ischemia, fractures, casts, splints, tourniquets, tight dressings, closure of fascial defects and incomplete skin release, crush injuries, and malpositioning on the operating table.

Increasing intracompartmental pressure results in decreased venous flow and narrows the arteriovenous perfusion gradient, resulting in diminished tissue perfusion. This condition is self-perpetuating, leading to a continuous feedback loop that must be broken with the timely initiation of definitive care. Cellular anoxia is the final common pathway of all compartment syndromes. However, the interrelation between increased compartment pressure, blood pressure, and loss of tissue perfusion leading to cell death ...

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