Chapter 47: Compartment Syndrome

GENERAL CONSIDERATIONS/HISTORY

Compartment syndrome (CS) has been identified as a disease state since 1881 by German surgeon Richard Von Volkmann.¹ However, the potential harm of increased intra-compartmental pressure was first observed by Hippocrates in 400 BC. Volkmann noted paralysis and contracture and suggested that it came simultaneously because of an interruption to the blood supply of the affected muscles.^1,2 The first surgeon to reproduce ischemic contracture was Paul Jepson in 1924 while working at the Mayo Foundation.¹ He demonstrated that prompt surgical decompression could prevent these contractures.¹

Acute compartment syndrome (ACS) is a condition in which increased pressure (from any source) within a closed space comprises the circulation to the tissues contained within this space² (Figures 47-1 and 47-2). Without urgent decompression, tissue ischemia, necrosis, and functional impairment will occur.^1,3,4 Almost any injury can cause this syndrome including fractures, soft tissue injury, crush syndrome, burns, decreased compartment size, vigorous exercise, and more (Figures 47-1 and 47-3).^2–4 According to a study by McQueen et al. (2000), which examined 164 patients with CS, 69% had an associated fracture of which approximately half were tibial shaft fractures (Figure 47-3).² CS is also frequently secondary to reperfusion following arterial occlusion.³

There are numerous risk factors for CS including young age, usually under 35, male gender, tibial fractures, high-energy forearm fractures, bleeding, and diathesis/anticoagulants (Figure 47-4).³ Alternatively, there are numerous risk factors for misdiagnosing ACS including altered level of consciousness, regional anesthesia, patient-controlled analgesia, children, and associated nerve injuries.³ Exertional compartment syndrome is divided into two forms: acute exertional compartment syndrome (AECS) and acute on-top-of chronic exertional CS. AECS exists when intracompartmental pressure is elevated to a level and duration such that immediate decompression is necessary to prevent necrosis, which occurs in individuals performing strenuous activity above his or her normal level of training.³ Acute on-top-of chronic exertional CS exists when a chronic CS proceeds to an acute form which requires decompression. For example, military recruits may be forced to exercise while suffering from a chronic exertional CS and need urgent fasciotomies.