What is compartment syndrome?
Acute compartment syndrome is a medical emergency that can have devastating, even fatal, consequences. If compartment syndrome goes undiagnosed, the complications can cause nerve and tissue death that can cause permanent sensory loss, amputation of limbs, even death due to sepsis.
A little anatomy
Our bodies are divided into a number of compartments surrounded by a tough connective tissue called fascia. Each compartment contains muscles and nerves creating a closed space.
Compartment syndrome (CS) is a medical emergency where the perfusion pressure (blood supply) in the veins or arteries in the compartment falls below the pressure in the surrounding tissues. This prevents proper circulation and function of the tissues resulting in ischemia (inadequate blood supply to muscles or organs). Prolonged CS can result in nerve and tissue death (called necrosis). Necrosis can mean that the limb must be amputated to prevent further spread of the tissue death.
What causes Compartment Syndrome?
There are many possible causes for compartment syndrome. Simply put, anything that can injure the tissue can result in compartment syndrome. Various studies have identified possible causes of compartment syndrome including:
- Long bone fractures;
- Vascular injuries;
- Severe burns;
- Crush injuries;
- Penetrating injuries;
- Muscle tears;
- Deep vein thrombosis;
- Over exertion (typically seen in runners who over train); and
- Tight casts.
However, the vast majority of compartment syndrome cases are caused by lower limb fractures of the tibia (more commonly known as your shin bone).
Are there different types of Compartment Syndrome?
Doctors have identified two different types of compartment syndrome, chronic and acute. Chronic compartment syndrome is frequently seen in competitive athletes. It is usually a product of over training and is usually found in both lower limbs. Symptoms of chronic CS tend to go away within several minutes of stopping the physical exertion that causes the pain.
Acute compartment syndrome usually happens after a traumatic event. In acute CS the symptoms become dramatically worse over a relatively short period of time and permanent nerve damage and muscle necrosis can happen within hours.
CS develops when the pressures in the tissues surrounding the veins and arteries in the compartment increase significantly. The increase in pressure compromises blood circulation resulting in nerve and muscle ischemia. When tissue pressures in the compartment get too high it requires immediate surgical intervention called a fasciotomy (cutting open the fascial compartment to release pressure within the compartment).
Other complications from Compartment Syndrome
In addition muscle damage that may require amputation, the tissue death causes release of a protein called myoglobin. Myoglobin can result in renal injury (trauma to your kidneys). In the advance stages of acute CS patients can suffer rhabdomyolysis (a syndrome that causes your muscle tissue to break down). This can also cause kidney failure. Typically fatalities associated with acute CS are due to kidney failure resulting in sepsis (an advanced and potentially fatal infection).
How do doctors diagnose compartment syndrome?
Traditionally physicians were taught the “5 P’s” (pain, paresthesia, pulselessness, pallor and paralysis) to identify compartment syndrome. However, there are actually 10 typical signs and symptoms of compartment syndrome. Most only develop in the later stages of CS when it may be too late to prevent permanent muscle and nerve damage.
Signs and Symptoms of Compartment Syndrome
- Pain out of proportion to the injury.
- Pain on passive stretching.
- Paresthesia (Tingling or numbness. What some people describe as a pins and needles sensation)
- Paresis (Partial loss of movement in the toes).
- Decreased sensation.
- Pallor (The limb looks white or dusky).
- Decreased pulses in the affected limb.
- Increased pressure. This is the only sign that is universally present in acute CS. It is the only way to definitively rule in or rule out CS.
- Tenseness of the compartment (However you cannot measure this if there is a cast on the affected limb).
- Decreased capillary refill (When you push on your fingernail, the time it takes for the nail to change from white back to pink).
Useful Lab Tests
If you are in the hospital your doctors typically run blood tests that provide them with helpful information that can help them diagnose compartment syndrome.
Creatine Kinase (CK) is an enzyme that is released in the presence of tissue damage. High CK should raise concerns with your doctor about possible tissue destruction.
The presence of myglobin in urine is also a sign of tissue or muscle damage. Increased myoglobin is associated with rhabdomyolysis.
Finally, if your blood tests show elevated potassium levels, this is seen in the early to later stages of rhabdomyolysis.
Pain is important!
Pain out of proportion to the injury is a cardinal sign of compartment syndrome. But typically pain will decrease over time as the nerves and tissues in the compartment start to die.
This means that your doctor may miss signs that you are suffering from acute compartment syndrome because your complaints of pain decrease over time. Or your pain may be masked by pain medication given to address your complaints of acute pain.
Diagnosis and Treatment of Compartment Syndrome
The only accepted treatment for suspected CS is immediate decompression of the affected compartment through surgery. Basically the surgeon has to open up the compartment to release the pressure inside.
Your muscles can survive ischemia (decreased blood flow) caused by CS for up to 4 hours without irreversible damage. But if your ischemia lasts 8 hours or more you may suffer irreversible damage.
While the time frame in which surgery must be performed depends on each patient’s circumstances it is generally accepted that permanent tissue death can occur within 6-10 hours of development of acute compartment syndrome.
In cases where you are wearing a plaster cast, releasing the cast can significantly reduce compartment pressures.
Some studies have found that hyperbaric oxygen can promote blood flow and oxygenation and reduce your swelling.
If you develop rhabdomyolysis as a result of compartment syndrome your doctor will treat you with fluids and monitor your kidney function and potassium levels.
Prognosis in Compartment Syndrome Cases
Acute compartment syndrome is a medical emergency that can have devastating and possibly fatal results. Muscles can tolerate upwards of eight hours of ischemia before permanent damage is incurred. Beyond eight hours tissue damage is usually irreversible. If a fasciotomy is performed within 12 hours following the onset of acute compartment syndrome the prognosis is usually good.
However, nearly 20% of patients who have suffered acute compartment syndrome have permanent nerve and motor deficits.
Have you suffered an injury caused by compartment syndrome?
If you have suffered an injury or amputation due to compartment syndrome, or if your loved one has died due to complications of compartment syndrome, you can contact us for a free consultation to determine if the injuries may have been due to medical malpractice. Call us in Halifax at 877-423-2050 or toll free in Atlantic Canada at 1-877-423-2050.