Compartment syndrome occurs when excessive pressure develops in one of the body’s compartments, exceeding the arterial pressure entering the compartment and so preventing blood from flowing in to supply the tissues. This can cause severe problems including great pain and tissue death if it is not treated quickly. This problem occurs mostly in the lower leg and in the forearm, where the muscles are all enclosed in a soft tissue section called a compartment, with the walls made up of bone and strong connective tissue called fascia. This makes the compartment inextensible and liable to pressure build up in certain circumstances.
The most common cause of compartment syndrome is a fracture of the tibia but there are other potential causes which include tissue crush injuries, tight dressings and plasters, other fractures and damage to blood vessels. If the syndrome develops the signs and symptoms are a loss of feeling in the area, loss of pulses and loss of the ability to move the limb. Surgical decompression is the primary form of management for diagnosed compartment syndrome. Potential complications include kidney failure, breakdown of muscle tissue and permanent contracture of the forearm muscles.
Whilst most compartment syndrome is acute following some kind of event, careful measurements of the pressures within the compartments of the leg have shown chronic compartment syndrome to be a clinical entity in situations such as excessive exercise performance. As the tissue pressure increases in the muscular and fascial compartment it starts to compromise the blood flow into the compartment, damaging the muscles and nerves. In the acute type the onset is fast and leads quickly to muscle and nerve damage which is irreversible unless treated urgently.
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.
Two kinds of factors are important for triggering compartment syndrome, either internal or external factors acting on the area. Wearing clothes too tight and the application of plasters or dressings too tightly can produce the required compression. Many potential internal factors exist such as swelling from a crushing injury, bleeding internally, doing excessive muscle building and fractures. As the pressure rises and overwhelms the blood pressure then blood flow stops, damaging the muscles and nerves and causing muscle death, leading to chemical changes which pull water into the compartment, increasing the pressure again.
Elevated pressure in a compartment requires prompt decompression surgically, a delay of 6 to 10 hours would lead to nerve damage, death of muscle tissue and of more widespread tissue areas. Muscle damage can result in the release of the chemical myoglobin into the vascular system which can induce fatal renal damage. In chronic compartment syndrome the muscles increase in volume as they exercise and this raises the compartment pressure, keeping the pressure elevated between the contractions of the muscles and so impairing blood flow. Cramp in the muscles then develops as the necessary amounts of blood are not supplied.
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 Physiotherapy 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 Leeds visit his website.
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