Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Compartment Syndrome


Related Terms

  • Capillary Perfusion Pressure
  • Compartmental Syndrome
  • CPP
  • Intercompartmental Pressure
  • Volkmann’s Contracture

Differential Diagnosis

Specialists

Comorbid Conditions

  • Abdominal trauma
  • Blood clots
  • Blood vessel injuries
  • Cellulitis
  • Gas gangrene
  • Internal bleeding
  • Kidney disease
  • Liver transplantation

Factors Influencing Duration

Factors that may influence the length of disability include promptness and extent of treatment, any complications, and the response of the individual. For compartment syndrome of the hand, duration depends on whether the dominant or nondominant hand was affected.

Medical Codes

ICD-9-CM:
729.71 - Nontraumatic Compartment Syndrome of Upper Extremity; Nontraumatic Compartment Syndrome of Shoulder, Arm, Forearm, Wrist, Hand and Fingers
729.72 - Nontraumatic Compartment Syndrome of Lower Extremity; Nontraumatic Compartment Syndrome of Hip, Buttock, Thigh, Leg, Foot and Toes
729.73 - Nontraumatic Compartment Syndrome of Abdomen
958.90 - Certain Early Trauma Complications, Traumatic Compartment Syndrome, Unspecified
958.91 - Certain Early Trauma Complications, Traumatic Compartment Syndrome of Upper Extremity
958.92 - Certain Early Trauma Complications, Traumatic Compartment Syndrome of Lower Extremity
958.93 - Certain Early Trauma Complications, Traumatic Compartment Syndrome of Abdomen
958.99 - Certain Early Trauma Complications, Traumatic Compartment Syndrome of Other Sites

Overview

Compartment syndrome (CS) is a serious condition that develops when tissue pressure (interstitial pressure) rises higher than pressure within blood vessels (perfusion pressure) within a closed space (compartment) in the body, with resulting ischemia and even necrosis of muscles and nerves. CS can be either acute or chronic and can be a limb- or life- threatening condition.

Compartments are formed by groupings of muscles, tendons, nerves, and blood vessels in the arms, legs, and trunk. Surrounding or covering these tissues is a tough membrane (fascia). The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.

CS is a painful condition that most often occurs following trauma, vascular injury, excessive activity, or vigorous exercise. It most commonly occurs in the extremities such as in the arms, hands, feet, or legs, but may also occur in the buttocks or abdomen. Acute CS develops over a period of hours after an injury when swelling or bleeding within a fascial compartment increases pressure on small blood vessels (capillaries) and nerves within the compartment. When the intramuscular tissue pressure becomes higher than the blood pressure inside the capillaries, the capillaries collapse, disrupting the flow of blood, oxygen, and nutrient delivery to nerve and muscle cells and causing them to die (ischemia). Without relief of the increased pressure, tissue necrosis and/or blood content abnormalities can occur resulting in permanent disability, kidney (renal) failure, or death.

Acute CS is always caused by excessive interstitial pressure within the compartment. However, many types of injury may result in increased tissue pressure by increasing fluid content within the compartment or by decreasing compartment size. These include blockage of circulation by a tight cast or dressing, tight surgical closure of the fascia, pressure on a blood vessel for a long period while sleeping (e.g., head on forearm or one leg folded under the other), or when an object has fallen on a limb and immobilized it. It can also be caused by prolonged external pressure on a limb during a period of low blood pressure (e.g., during surgery or unconsciousness); swelling or bleeding (hemorrhage) within a muscle group from burns; traumatic injury; frostbite; infection; or allergic reaction to insect bites. Acute CS from post-surgical complications can arise from edema after a return of blood flow (revascularization) following repair of a blood vessel injury, or from blockage (obstruction) of blood vessels from edema resulting from the intravenous administration of fluids. Severe bruising of a muscle resulting from a strong blow, a fall, or a heavy object falling on a limb (crush injury) can also result in CS. The most common cause of acute compartment syndrome is fracture of shin bone (tibia) of the lower leg.

Abdominal CS has a systemic effect on organ function. It can be caused by abdominal trauma, an inflamed pancreas (pancreatitis), internal hemorrhage, intestinal blockage (obstruction), liver transplantation, ruptured aortic aneurysm, severe intra-abdominal infection, or the use of pneumatic antishock garments or military antishock trousers. Abdominal CS can be fatal if not diagnosed and treated promptly.

Chronic CS is most often caused by injury from vigorous exercise or overuse of a muscle group and develops most frequently in the legs. Although the syndrome stops when the offending activity stops, compartment pressure can stay elevated for hours afterward, causing pain and numbness. This can present significant problems for endurance athletes such as runners or cyclists.

Incidence and Prevalence: A tibial fracture is responsible for 2% to 12% of cases of compartment syndrome (Rasul). About 30% of limbs receiving vascular injury develop CS; approximately 69% are associated with fracture and, of these, 50% are fractures of the long bone of the lower leg (tibia) (Rasul). CS is diagnosed more frequently in men than in women (Rasul).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Acute compartment syndrome commonly occurs following trauma to a limb such as fracture or crush injury. Individuals most at risk for acute CS are those who sustain high-velocity injuries, fractures of a long bone, penetrating injuries (e.g., stabbings, gunshot wounds), or crush injuries, as well as those involved in collision sports such as football, ice hockey, or rugby. Runners, cross-country skiers, soccer players, cyclists, and walkers are at greater risk for chronic CS than the general population.

Risk is increased in injured individuals who are receiving anticoagulation therapy for any reason. Although high energy injuries are associated with significant soft tissue trauma, they are often open and therefore at less risk for a compartment syndrome. The highest risk is with high energy injuries that have a fracture with the skin closed.

Source: Medical Disability Advisor



Diagnosis

History: Classically "6 Ps" are described related to compartment syndrome: pain, paresthesia, pallor, paralysis, pulselessness (though this is rarely seen), and poikilothermia (the affected limb may be cold); another P described is pressure (elevated interstitial pressure). The individual complains of pain, muscle tightness, and decreased movement of the affected limb. In the acute onset, the pain is usually more intense that what would be expected from the injury itself. Limb weakness, numbness (sensory deficits), and/or a burning or tingling sensation (paresthesia) also may be reported. There may be a history of a recent injury, surgery, severe trauma such as a high-velocity accident or crush injury, or recent use of an intravenous line for treatment purposes. Individuals with CS of the buttocks may complain of referred pain to the legs. The athlete with chronic CS may complain of leg pain that occurs while exercising and that is relieved when at rest; this pain may have been experienced for weeks or months. The individual with abdominal CS complains of bloating (abdominal distension) and breathing difficulties and may have a recent history of abdominal surgery or trauma. When asked about medications, the individual may report taking anticoagulation medicine (e.g., aspirin, heparin, warfarin [Coumadin]).

Physical exam: The affected limb is compared to the unaffected limb and is usually found to be swollen and tense over the affected compartment. Initial symptoms typically include tingling or burning sensations. Eventually the muscle feels "full." Muscle stretching causes pain or tingling. Sometimes the level of pain observed seems inconsistent with the degree of injury. Numbness or possible paralysis may be present, indicating that cell death has begun and immediate reduction of interstitial pressure is needed. The pulse in the wrist or ankle is usually present because the pressures associated with CS are frequently much lower than blood pressure. Individuals with abdominal CS may exhibit abdominal distension, increased breathing rate (tachypnea), rapid heart rate (tachycardia), and decreased urine output (oliguria).

Tests: The compartment pressure (intracompartmental tissue fluid pressures) can be measured by several different types of commercial devices. Most use a fine tube (catheter) which is inserted into the affected area to a point just below the fascia. Blood tests may include a blood chemistry panel and a complete blood count (CBC), complete metabolic profile (CMP), prothrombin time (PT) and partial thromboplastin time (PTT) to examine clotting factors, and creatine phosphokinase (CPK) and myoglobin to assess for possible muscle injury. Urinalysis (especially to check for blood in urine [hematuria]), and urine myoglobin also may be performed. Plain x-rays of the affected limb and ultrasound scanning may be performed. Ultrasonography is not diagnostic for CS, but it helps in the differential diagnosis. Diagnosis of abdominal CS is aided by bladder pressure monitoring using a urinary catheter attached to either a fluid manometer or transducer. Chronic CS may require measurement of intramuscular pressure before exercise, one minute after exercise, and then five minutes after exercise; pressures remaining high are diagnostic for chronic CS.

Source: Medical Disability Advisor



Treatment

Acute CS is a medical emergency. Time is critical in treating CS as irreversible nerve damage can occur after 6 hours of increased intracompartmental pressure. The 6 hour guide is impacted by how quickly the CS occurs and how much pressure occurs in the compartment. Non-surgical treatment of acute CS involves removing any restricting dressings or casts, applying ice, and maintaining the affected limb in a position level with the body. Oxygen may be provided to increase the amount of arterial oxygen and possibly delay tissue damage. Hyperbaric (forced oxygen) treatment may be considered but open decompression should not be delayed for hyperbaric treatments. Medication may be administered to reduce inflammation but again, should not be used to delay surgical decompression. Non-surgical treatment is seldom effective for acute CS ("Compartment Syndrome"). Immediate surgical treatment is indicated if symptoms do not resolve quickly or signs of paralysis are present.

Surgical decompression is the “gold standard” for treatment of acute CS. If surgery is required, deep incisions are made (fasciotomy) over the affected compartment to reduce pressure. Fasciotomy of the hand usually requires four incisions, two on the back of the hand, one into the mound of tissue at the base of the thumb (thenar region), and one into the tissue at the base of the little finger (hypothenar region). Fasciotomy of the lower leg usually requires two incisions, one situated on the outer front side (anterolateral) and the other situated on the center back (posteromedial). Fasciotomy of the upper leg is usually performed by making one incision in the side of the thigh. Fasciotomy of the foot involves incising the affected muscle compartment of the foot. The incisions are left open and sterile dressings applied. The incisions are closed with stitches (sutures) or skin grafts about 5 to 10 days later. Antibiotics and analgesics are provided, as needed.

In high-risk cases, fasciotomy may be performed as a preventive (prophylactic) measure. Factors indicative of fasciotomy include a lengthy delay between injury and surgery, an episode of low blood pressure (hypotension) prior to surgery, considerable preoperative swelling of the injured limb, a crushed limb in which both arteries and veins are injured, and any situation in which major venous repair (ligation) is required.

Chronic CS is not a medical emergency. It may be treated conservatively with rest, ice, elevation, analgesics, and avoiding the activities that result in pain and swelling. The individual may gradually return to the activity that caused the syndrome. Fasciotomy may be necessary should conservative treatment fail. Increased cushioning in the shoes may be recommended.

Mild abdominal CS is treated conservatively by elevating the head of the bed and encouraging the individual to cough and breathe deeply. Moderate to severe abdominal CS is treated by cutting open the abdomen (laparotomy) for immediate pressure relief (decompression) and by removing the fluid causing the increased pressure. In trauma cases, the abdominal incision may be left open to drain for a few days to prevent recurrence of the CS.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Crush Injuries and Compartment Syndrome
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

The affected limb may regain full function or be permanently disabled depending on how much damage has occurred to the soft tissues in the compartment. The damage is related to how quickly the fasciotomy was performed after the onset of symptoms. Return of full limb function is expected if fasciotomy is performed within 6 hours. If not treated within 12 hours, functional abnormality usually occurs, and loss of limb (amputation) is common. Fasciotomy results in long skin scars and skin grafts may be needed in some cases. Conservative treatment for chronic and abdominal CS can be effective for mild cases. Surgical decompression for abdominal CS has a good success rate, but unrecognized or untreated abdominal CS may result in multiple organ failure and death.

Source: Medical Disability Advisor



Rehabilitation

The rehabilitation program for compartment syndrome will depend on what caused the condition. It is important to identify the underlying etiology. CS may result from an acute trauma or an offending activity, such as running or skiing (Brennan, Kleigman). If the cause is activity-related and not acute, the individual should be instructed in activity modifications so as to reduce the factors associated with CS (Yeung; Kliegman). If the CS occurred in the lower extremities, the feet should be assessed for pronation and treated with orthotic shoe inserts; shock absorbing insoles may also be recommended (Barr).

If CS results from an acute trauma, then surgery is usually indicated, followed by rehabilitation. Rehabilitation depends on the integrity and vascularity of the released muscle and surrounding soft tissue. When indicated, therapy begins with gentle active range of motion exercise of the adjacent joints. During this stage, exercise must be taught and progressed gradually so as not to compromise the healing of the soft tissue. Gait training with an assistive device may be necessary following lower extremity surgical release, with the amount of weight bearing as indicated by the treating surgeon. Once the soft tissue is healed and the wound is closed, therapy continues with progressive stretching exercises and advances to strengthening exercises (Hovius).

If the CS is chronic, then conservative treatment may be beneficial. If the offending activity leading to the symptoms can be identified, it should be modified or discontinued. This treatment should follow the principles of PRICE (protection, rest, ice, compression, elevation) until swelling is controlled (Barr; Kliegman). Exercise should begin with gentle active range of motion exercises. As soon as symptoms subside, therapy should progress with stretching and strengthening exercises until full function returns. Therapists should always carefully monitor signs or symptoms of recurrence in these individuals as they progress through rehabilitation. Surgery (fasciotomy) may be necessary if conservative therapy fails.

Additional information may provide insight into the rehabilitation needs of these individuals (Pell).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistCompartment Syndrome
Occupational/Hand/Physical TherapistUp to 6 visits within 6 weeks
Surgical
SpecialistCompartment Syndrome
Occupational/Hand/Physical TherapistUp to 15 visits within 6 weeks
Note on Nonsurgical Guidelines: Applies to chronic compartment syndrome.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Muscle and nerve cell death will occur if the pressure within the compartment is not relieved within 6 hours. This may lead to pain, deformity, paralysis, permanent muscle contraction (Volkmann's contracture), or loss of limb. More severe complications include systemic infection (sepsis) and renal failure. Complications associated with abdominal CS include cardiac or circulatory abnormalities, renal failure, changes in lung (pulmonary) function, and increased pressure in the brain. Unrecognized and/or untreated abdominal or limb compartment syndromes can be fatal.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Movement of the affected limb is restricted until the individual recovers. The individual with upper limb compartment syndrome is temporarily unable to lift and carry heavy or bulky objects, operate equipment, or perform other tasks requiring use of both hands. If the dominant arm or hand was affected, the individual may be unable to write legibly or type well. Likewise, compartment CS in the dominant hand affects fine motor skills such as those needed to work in a laboratory. These individuals may require a temporary or permanent reassignment of duties. CS in a lower limb may affect the individual's ability to stand or sit for extended periods. The effect of any permanent movement limitations as a result of limb CS needs to be fully evaluated. Individuals recovering from abdominal surgery are temporarily unable to lift heavy objects or operate machinery. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Risk: Risk for CS is dependent on the extent of the original injury, whether the injury was open or closed, the amount of soft tissue damaged, and the general health of the individual. Older individuals or individuals in poor health with pre-exiting vascular conditions are at increased risk for CS. High energy closed injuries with fractures are at higher risk.

Capacity: Functional capacity is dependent on the limb involved (upper or lower or both), the severity of the CS, and the amount of tissue damaged. Significant contractures can limit range of motion and therefore prevent specific job tasks from being performed.

Tolerance: CS is a very painful condition and will limit functional capacity until the pressure is relieved and the soft tissues healed. Return to activities will be limited by pain.

Accommodations: Accommodations will be required if permanent damage has occurred to the soft tissues.

Source: Medical Disability Advisor



Maximum Medical Improvement

120 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was compartment syndrome confirmed by measuring compartment pressure with a tonometer?
  • Were conditions with similar symptoms ruled out?
  • Was CS acute or chronic?
  • If chronic, were compartment pressure measurements taken before and after exercise?
  • Did individual experience CS after surgery? After trauma? From other causes?
  • Did individual sustain a strong blow, a fall, or a heavy object falling on a limb (crush injury)?
  • Did individual have bone fracture(s)?
  • Did individual have abdominal trauma, pancreatitis, internal hemorrhage, intestinal blockage, liver transplantation, ruptured aortic aneurysm, or severe intra-abdominal infection?
  • Did individual wear pneumatic antishock garments or military antishock trousers?
  • Was there a delay in the diagnosis of CS? If so, how long?

Regarding treatment:

  • Was fasciotomy performed promptly (within 6 hours) of occurrence for acute CS?
  • Was conservative treatment used for chronic CS? Did it relieve symptoms?
  • If individual had chronic CS, were aggravating activities modified? Were shock absorbing insoles used?
  • Is individual going to physical therapy?
  • If a conservative treatment failed to relieve symptoms of chronic CS, has surgical intervention (fasciotomy) been considered?

Regarding prognosis:

  • Was fasciotomy performed for acute CS within 6 hours? Was there time delay between injury and surgery?
  • Did renal failure occur?
  • Was limb amputation necessary?
  • Has individual followed prescribed physical and occupational therapy on a regular basis?
  • Has adequate time elapsed to allow for complete recovery and return of strength and coordination of the dominant extremity?
  • Has employer been able to make appropriate work accommodations to allow for the recovery?
  • Have there been any complications such as loss of movement (paralysis) or permanent muscle contraction?
  • Would individual benefit from consultation with an appropriate specialist (physiatrist, nephrologist, cardiologist, pulmonologist, neurologist)?
  • Are there any comorbid conditions that may affect ability to recover? If so, have these conditions been addressed in the treatment plan?

Source: Medical Disability Advisor



References

Cited

"Compartment Syndrome." American Academy of Orthopaedic Surgeons. Oct. 2009. American Association of Orthopaedic Surgeons. 9 May 2014 <http://orthoinfo.aaos.org/topic.cfm?topic=A00204>.

Barr, Karen B. "Chapter 58 - Compartment Syndrome." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Brennan, F. H., and S. F. Kane. "Diagnosis, Treatment Options, and Rehabilitation of Chronic Lower Leg Exertional Compartment Syndrome." Current Sports Medicine Reports 2 5 (2003): 247-250. National Center for Biotechnology Information. Oct. 2003. National Library of Medicine. 9 May 2014 <http://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+12959704>.

Hovius, S. E., and J. Ultee. "Volkmann's Ischemic Contracture. Prevention and Treatment." Hand Clinic 16 4 (2000): 647-657. National Center for Biotechnology Information. Nov. 2000. National Library of Medicine. 9 May 2014 <http://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+11117054>.

Kliegman, Robert M., et al., eds. "Lower Leg Pain: Shin Splints, Stress Fractures and Chronic Compartament Syndrome." Nelson Textbook of Pediatrics. 18 ed. Saunders, Elsevier, 2007. 686-687.

Pell, R. F. , H. S. Khanuja, and G. R. Cooley. "Leg pain in the running athlete." Journal American Academy Orthopedic Surgery 12 4th (2004): 396-404.

Rasul, Abraham T. "Acute Compartment Syndrome." eMedicine. Ed. Consuelo T. Lorenzo. 9 May. 2013. Medscape. 13 May 2014 <http://emedicine.medscape.com/article/307668-overview>.

Yeung, E. W., S. S. Yeung, and L. D. Gillespie. "Interventions for Preventing Lower Limb Soft-Tissue Injuries in Runners: Update." Cochrane Database of Systematic Reviews 7 (2011): CD001256. National Center for Biotechnology Information. Jul. 2011. National Library of Medicine. 9 May 2014 <http://www.ncbi.nlm.nih.gov/pubmed/21735382>.

Source: Medical Disability Advisor






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