| Compartment syndrome (CS) is a serious condition that develops when pressure within blood vessels (perfusion pressure) drops lower than tissue pressure within a closed space (compartment) in the body. CS can be either acute or chronic and can be limb- or life- threatening condition.
A compartment is formed by muscle groups that contain nerves and blood vessels. The compartment is covered by a tough, inelastic membrane (fascia) that is not able to expand sufficiently when pressure increases within the space. The resulting syndrome is a painful condition that most often occurs following trauma, vascular injury, excessive activity, or vigorous exercise. CS most commonly occurs in the extremities such as in the arms, hands, feet, or legs, but may also occur in the buttocks or abdomen. Untreated, severe compartment syndrome can cause a series of physiologic events that may eventually lead to kidney (renal) failure and death.
Acute compartment syndrome develops over a period of hours after an injury when swelling or bleeding within a muscle compartment increases pressure on small blood vessels (capillaries) and nerves. 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 or death.
Acute CS is always caused by excessive pressure. However, many types of injury may result in increased pressure by increasing fluid content within the compartment or 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 (edema) or bleeding (hemorrhage) within a muscle group from burns, traumatic injury, frostbite, infection, or allergic reaction to insect bites. CS from post-surgical complications can arise from edema after a return of blood flow (revascularization) following repair of blood vessel injury or blockage (obstruction) or 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 can also result in compartment syndrome. The most common cause of acute compartment syndrome is fracture of shin bone (tibia) of the lower leg.
Abdominal compartment syndrome 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 compartment syndrome can be fatal if not diagnosed and treated promptly.
Chronic compartment syndrome is most often caused by injury from vigorous exercise or overuse of a muscle group and develops most often 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.Risk: Acute compartment syndrome commonly occurs following trauma to a limb such as fracture or crush injury. Individuals most at risk for acute compartment syndrome are those who incur high-velocity injuries, fractures of a long bone, penetrating injuries (e.g., stabbings, gunshot wounds), or crush injuries, and 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 compartment syndrome than the general population. Risk is increased in injured individuals who are receiving anticoagulation therapy for any reason. Incidence and Prevalence: Fracture or other injury to the lower extremities (legs or feet) represents 2% to 12% of cases of compartment syndrome (Paula). About 30% of limbs receiving vascular injury develop compartment syndrome; approximately 69% are associated with fracture and, of these, 50% are fracture of the long bone of the lower leg (tibia) (Paula). CS is diagnosed more frequently in men than in women (Paula). |
Source: Medical Disability Advisor
| History: The individual complains of pain, muscle tightness, and decreased movement of the affected limb. 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 compartment syndrome of the buttocks may complain of referred pain to the legs. The athlete with chronic compartment syndrome 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 compartment syndrome 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. The affected limb usually is swollen and tense over the affected compartment. Muscle stretching causes pain or tingling. Sometimes the level of pain observed seems inconsistent with the degree of injury. Numbness may be present or possible paralysis, indicating that cell death has begun and immediate restoration of pressure is needed. The pulse in the wrist or ankle is usually present. Individuals with abdominal compartment syndrome may exhibit abdominal distension, increased breathing rate, rapid heart rate (tachycardia), and decreased urine output. Tests: The compartment pressure (intracompartmental tissue fluid pressures) is measured using a tonometer in which a fine tube (catheter) 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), 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 rule out differential diagnoses. Diagnosis of abdominal compartment syndrome is aided by bladder pressure monitoring using a urinary catheter attached to either a fluid manometer or transducer. Chronic compartment syndrome 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 compartment syndrome. |
Source: Medical Disability Advisor
| 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. Non-surgical treatment of acute compartment syndrome 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. Medication may be administered to reduce inflammation. Non-surgical treatment is seldom effective for acute compartment syndrome ("Compartment Syndrome"). Immediate surgical treatment is indicated if symptoms do not resolve quickly or signs of paralysis are present.
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 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 compartment syndrome 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 compartment syndrome is treated conservatively by elevating the head of the bed and encouraging the individual to cough and breathe deeply. Moderate to severe abdominal compartment syndrome 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 compartment syndrome. |
Source: Medical Disability Advisor
| The affected limb may regain full function or be permanently disabled depending on how quickly 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 compartment syndrome can be effective for mild cases. Surgical decompression for abdominal compartment syndrome has a good success rate, but unrecognized or untreated abdominal compartment syndrome may result in multiple organ failure and death. |
Source: Medical Disability Advisor
| Note on research and authorship The rehabilitation program for compartment syndrome will depend on what caused the condition. It is important to identify the underlying etiology. Compartment syndrome may result from an acute trauma or an offending activity, such as running or skiing (Brennan). If the cause is activity-related, the individual should be instructed in activity modifications so as to reduce the factors associated with compartment syndrome (Yeung; Touliopolous).
If compartment syndrome 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. Once the soft tissue is healed and the wound is closed, therapy continues with range of motion exercises and advances to strengthening exercises (Hovius).
If the compartment syndrome 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 (Braddom). 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. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical | |
| Physical, Occupational or Hand Therapist | | Up to 15 visits within 6 weeks | | | | | | | | Surgical | |
| Physical, Occupational or Hand Therapist | | Up to 12 visits within 6 weeks | |
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| 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
| Muscle and nerve cell death will occur if the pressure within the compartment is not relieved within 6 to 8 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 compartment syndrome 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
| 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 syndrome 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. Compartment syndrome 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 compartment syndrome 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. |
Source: Medical Disability Advisor
| 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?
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Were conditions with similar symptoms ruled out?
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Was compartment syndrome acute or chronic?
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If chronic, were compartment pressure measurements taken before and after exercise?
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Did individual experience compartment syndrome after surgery? After trauma? From other causes?
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Did individual have bone fracture(s)?
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Was there a delay in the diagnosis of compartment syndrome? If so, how long?
Regarding treatment:
- Was fasciotomy performed promptly (within 6 hours) of occurrence for acute CS?
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Was conservative treatment used for chronic CS? Did it relieve symptoms?
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If a conservative treatment failed to relieve symptoms, has surgical intervention (fasciotomy) been considered?
Regarding prognosis:
- Has individual followed prescribed physical and occupational therapy on a regular basis?
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Has adequate time elapsed to allow for complete recovery and return of strength and coordination of the dominant extremity?
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Has employer been able to make appropriate work accommodations to allow for the recovery?
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Have there been any complications such as loss of movement (paralysis) or permanent muscle contraction?
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Would individual benefit from consultation with an appropriate specialist (physiatrist, nephrologist, cardiologist, pulmonologist, neurologist)?
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Are there any comorbid conditions that may affect ability to recover? If so, have these conditions been addressed in the treatment plan?
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Source: Medical Disability Advisor
| Braddom, Randolph L. Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: W.B. Saunders, 2000.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. National Library of Medicine. 6 Aug. 2008 <PMID: 12959704>. "Compartment Syndrome." American Academy of Orthopaedic Surgeons. Jul. 2007. American Association of Orthopaedic Surgeons. 13 Mar. 2009 <http://orthoinfo.aaos.org/topic.cfm?topic=A00204>. 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. National Library of Medicine. 6 Jul. 2008 <PMID: 11117054>. Paula, Richard. "Compartment Syndrome, Extremity." eMedicine. Eds. William Chiang, et al. 10 Dec. 2008. Medscape. 13 Mar. 2009 <http://emedicine.medscape.com/article/828456-overview>. Touliopolous, S., and E. B. Hershman. "Lower Leg Pain. Diagnosis and Treatment of Compartment Syndromes and other Pain Syndromes of the Leg." Sports Medicine 27 3 (1999): 193-204. National Center for Biotechnology Information. National Library of Medicine. 13 Mar. 2009 <PMID: 10222542>. Yeung, E. W., and S. S. Yeung. "Interventions for Preventing Lower Limb Soft-Tissue Injuries in Runners." Cochrane Database System Review 2 (2001): CD001256. National Center for Biotechnology Information. National Library of Medicine. 6 Aug. 2008 <PMID: 11686985>. |
Source: Medical Disability Advisor
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