Compartment syndrome is characterized by development of pressure within a muscle compartment beyond limits. Such a process causes the blood flow to decrease giving rise to debilitating conditions.
Presentation
Severe pain is the classical symptom of compartment syndrome. The pain usually does not respond to over the counter medications. In addition, in severe cases, compartment syndrome may present with the following signs and symptoms [7]:
- Weakness
- Pain that gradually gets worse
- Development of parasthesia in the affected area
- Skin of the affected area turns pale
- Experiencing great difficulty in moving the affected area
- Experiencing severe pain when the affected area is stretched or pulled
Entire Body System
- Swelling
Sometimes, the swelling can be severe enough that the skin incision cannot be closed immediately. The incision is surgically repaired when swelling subsides. Sometimes a skin graft is used. [orthoinfo.org]
However, the condition worsened with increasing pain, loss of sensation, tense swelling, and severe pain to any stretch of the tissues. Thus the patient received fasciotomy followed by repeat and thorough debridement. [ncbi.nlm.nih.gov]
Call your provider right away if you have had an injury and have severe swelling or pain that does not improve with pain medicines. There is probably no way to prevent this condition. [nlm.nih.gov]
- Weakness
When to see a doctor If you have recurring unusual pain, swelling, weakness, loss of sensation or soreness while exercising or practicing sports activities, talk to your doctor. [mayoclinic.com]
While recovering postoperatively, persistent weakness was noted in the right lower limb. Results of electrodiagnostic testing were consistent with a lumbosacral radiculoplexopathy. [ncbi.nlm.nih.gov]
- Disability
Pain and disability typically associated with CECS were greatly reduced for up to 1 year after intervention. Surgical intervention was avoided for all patients. [ncbi.nlm.nih.gov]
- Pallor
Do not wait for the development of pallor, absence of pulse or paralysis to consult surgery. These are late findings that may only arise once the limb is non-salvageable. [coreem.net]
Poikilothermia, paralysis, pallor, and pulselessness = late findings indicative of complete ischemia and poor prognosis. 4 Evaluation: Assess ABCs and obtain VS. [emdocs.net]
When assessing for neurovascular integrity, remember the five Ps: pallor, pain, pulse, paralysis and paraesthesia. Pallor Pallor is a good indicator of whether the extremity is being perfused, distal to the cast or injury. [ausmed.com]
[…] extreme pain out of proportion to the injury, - pain on passive ROM of the fingers or toes (stretch pain of the involved compartment): - patient will usually hold injured part in a position of flexion to maximally relax the fascia and reduce pain; - pallor [wheelessonline.com]
The classic signs are the five p’s – pulselessness, pallor, paralysis, paresthesia, and pain (often out of proportion to the clinical situation) By the time a patient is experiencing the 6 P’s, the risk of morbidity after fasciotomy is already very high [openanesthesia.org]
- Poikilothermia
Poikilothermia, paralysis, pallor, and pulselessness = late findings indicative of complete ischemia and poor prognosis. 4 Evaluation: Assess ABCs and obtain VS. [emdocs.net]
Poikilothermia Difference in the injured area’s warmth compared to the contralateral location. If the affected area feels cooler than the unaffected area, then this would suggest that the area cannot thermoregulate and has vascular compromise. [pedemmorsels.com]
Historically, the mnemonic memory device for compartment syndrome is the "5 Ps" (pain, paresthesia [change in sensation], pallor [pale coloration], paralysis, and poikilothermia [inability to control temperature]; some authors include pulselessness), [medicinenet.com]
Gastrointestinal
- Nausea
A 31-year-old male patient with chronic constipation of unknown aetiology presented emergently with worsening nausea, vomiting and abdominal distension of one week duration. On examination, his abdomen was distended with minimal tenderness. [ncbi.nlm.nih.gov]
Musculoskeletal
- Leg Pain
Leg pain or cramps at night was reported by 24% of the respondents. Age, rheumatic disease, use of hormone medication, heart failure, leg oedema, and peripheral arterial disease were all significantly associated with leg pain or cramps (P 15mmHg. [ncbi.nlm.nih.gov]
[…] compartment syndrome fasciotomy leg pain EICS, exercise induced compartment syndrome Recurrent leg pain is a common problem in very active people. [doi.org]
- Calf Pain
CASE: A 15-year-old female competitive high school basketball player presented as an outpatient with a 3-month history of bilateral exertional calf pain. [ncbi.nlm.nih.gov]
Pain Shin Pain Achilles Injuries Achilles Tendonitis / Tendinitis Achilles Tendon Rupture Retrocalcaneal Bursitis Calf Pain Calf Muscle Tear Shin Pain Shin Splints Stress Fracture Tibialis Posterior Tendinopathy Muscle Injuries Compartment Syndrome Muscle [physioworks.com.au]
Clinical diagnosis is hard because patients usually present with 1 of these signs and the rest when it is “too late” 6ps : PAIN, Pallor, Pulselessness, Paresthesias, Paralysis, Perishingly cold/Pudgy calf Pain is the earliest sign/ Pain w/ passive stretching [sinaiem.org]
- Muscle Tenderness
Severe pain during exercise that typically goes away an hour after stopping Pain on both sides of the body, such as in both legs Fullness or tightness in the muscle Tender, aching muscles Muscle weakness Numbness, tingling In severe cases, foot drop—a [uvahealth.com]
Symptoms may include: Severe pain during exercise that typically goes away an hour after stopping Pain on both sides of the body, such as in both legs Fullness or tightness in the muscle Tender, aching muscles Muscle weakness Numbness, tingling In severe [cancercarewny.com]
Muscle tenderness and swelling. Excessive pain on passive movement, increasing pain despite immobilisation. Peripheral pulses may still be present. [patient.info]
- Myalgia
However, CCS patients may instead experience both increased leg pain and a proximal myalgia, which is possibly a referred pain. [ncbi.nlm.nih.gov]
Finnish verenvuodon aiheuttama lihasaitio- oireyhtymä English compartment syndrome secondary to a bleeding Last Update: 2017-04-26 Usage Frequency: 2 Quality: Finnish yleinen: lihasaitio-oireyhtymä, lihassärky English common: compartment syndrome, myalgia [mymemory.translated.net]
- Foot Pain
CCS may be considered an uncommon though important cause of exercise-induced leg and/or foot pain. History: CCS of the leg was first described in1956 by Mavor. Up until 1975 only nine case reports were published on CCS of the leg. [aapsm.org]
He continued to have persistent marked edema to the foot. The patient reported minimal foot pain relief since the time of the index surgery. [podiatrytoday.com]
Urogenital
- Kidney Failure
Treatment will also be directed to the underlying cause of the compartment syndrome and to try to prevent other associated complications including kidney failure due to rhabdomyolysis. [medicinenet.com]
failure, 057784, ショック症状, ショックショウジョウ, shock(symptom), 040187, shock, 外傷, ガイショウ, injury, 023276, 虚血, キョケツ, ischemia, 023309, *, 筋疾患, キンシッカン, muscular disease, 039944, 切開術, セッカイジュツ, incision, 040916, ドレナージ, ドレナージ, drainage(therapy), 054663, drainage [togodb.biosciencedbc.jp]
This can lead to kidney failure or can affect the heart’s electrophysiology, leading to arrhythmias [irregular heartbeats]. When you have millions of cells spilling their contents into the blood-stream, it really affects the body’s physiology. [scientificamerican.com]
Rhabdomyolysis and subsequent kidney failure are also possible complications. In some case series, rhabdomyolysis is reported in 23% of patients with ACS. [en.wikipedia.org]
- Renal Insufficiency
Although intravesical pressures were not documented because of the nature of her reconstruction, her ACS-type findings were (1) abdominal pain, (2) melena, (3) pulmonary hypoinflation, (4) renal insufficiency, (5) tachycardia, and (6) segmental ischemic [ncbi.nlm.nih.gov]
ニンゲン, human(sociology), 041431, human, 雄性, ユウセイ(オス), maleness, 037186, ユウセイ, 性, セイ, sex, 011494, 投与経路, トウヨケイロ, administration route, 054972, 投与, トウヨ, administration(biology), 054973, administration, 身体部位, シンタイブイ, body region, 028842, 腎不全, ジンフゼン, renal [togodb.biosciencedbc.jp]
- Dark Urine
It also presents with muscle pain but also a picture of more generalised malaise Look for dark urine, deteriorating renal function and raised creatinine kinase Consultant a renal physician if acute renal failure in this context Diagnosis of compartment [oxfordmedicaleducation.com]
Neurologic
- Paresthesia
He notes the development of right hand paresthesias during transport. Triage VS: BP 138/91, HR 110, T 99.1 Oral, RR 12, SpO2 99% on room air. [emdocs.net]
The probability of compartment syndrome in the patient presenting with pain, paresthesias, paresis, and pain with passive stretch, all of which were positive findings in this patient, has been reported to be 98%. [ncbi.nlm.nih.gov]
Pain with passive stretching, or paresthesia can be early signs of compartment syndrome. [openanesthesia.org]
- Burning Sensation
After admission to inpatient rehabilitation, the patient complained of pain, burning sensation, and numbness in the distal right lower limb. [ncbi.nlm.nih.gov]
A tingling or burning sensation (paresthesias) in the muscle may be present. Numbness or paralysis in the limb may signal that cell death has begun and it may be difficult to restore function. [websites.sportstg.com]
You may feel a burning sensation or a tightness around the affected area. Pins and needles can also occur in the arm or leg affected by compartment syndrome. You may also have reduced sensation when the skin on the affected limb is touched. [patient.info]
There may also be tingling or burning sensations (paresthesias) in the skin. The muscle may feel tight or full. Numbness or paralysis are late signs of compartment syndrome. They usually indicate permanent tissue injury. [orthoinfo.org]
- Sciatica
Fracture Tibialis Posterior Tendinopathy Muscle Injuries Compartment Syndrome Muscle Strain Cramps DOMS - Delayed Onset Muscle Soreness Overuse Injuries Systemic Conditions Rheumatoid Arthritis Fibromyalgia Psoriatic Arthritis Lupus Neurological Conditions Sciatica [physioworks.com.au]
- Hypesthesia
The radial side of his left forearm was markedly swollen on presentation, and he suffered severe pain that worsened with ulnar flexion of the wrist; no paralysis or hypesthesia was observed. [ncbi.nlm.nih.gov]
Workup
In majority of the cases, physical examination of the signs and symptoms would be enough to diagnose the condition. No kind of laboratory workup is indicated. In physical examination, the pressure in the compartment is directly measured with the help of needle that is attached to pressuremeter. The pressure in the compartment is measured before and after the activity [8].
In case of acute compartment syndrome with associated trauma physical examination along with the following analysis becomes necessary:
- Renal function analysis
- Urinalysis
- Creatine phosphokinase
- Urine myoglobin
- Concentration of creatine phosphokinase of about 1000 to 5000 U/mL suggests the onset of compartment syndrome.
Treatment
For acute compartment syndrome, surgery is the only available option to treat the condition. In this method, long incisions are made in the affected area to release the pressure. The wounds are usually covered with a sterile bandage and are closed in a second surgical procedure [9].
In case of any bandage or cast that is causing the condition, it should be loosened to relieve the pressure. Medications such as opioids and NSAIDs can be administered for providing relief from pain [10]. It is advised that side effects of the medications should be considered before prescribing to patients.
Prognosis
Prognosis of the condition largely depends on when the condition was diagnosed and when was the treatment initiated. In a research study, it has been reported that complete restoration of limb function could be attained when fasciotomy was carried out within 6 hours of injury [6]. When the treatment is not initiated within 12 to 24 hours of compression, then permanent damage to the nerve and muscles can occur.
Etiology
Development of excessive pressure inside a muscle compartment causes compartment syndrome. There are several factors that lead to increase in the pressure; these include: Fractures, injuries, infections, development of muscular hypertrophy, prolonged limb compression and burns causing development of acute compartment syndrome.
Chronic compartment syndrome is a common phenomenon for athletes and occurs due to repetitive movements or activities such as running, exercising, cycling and playing sports. All these can cause pressure inside the muscle to increase causing pain and tightness in the affected areas [2].
Epidemiology
The exact prevalence of compartment syndrome is not known. It has been reported that patients who have suffered vascular injury are more prone to develop compartment syndrome. It has been estimated that about 19% patients with vascular injury required fasciotomy to treat acute compartment syndrome [3]. In a study of military personnel of United States, it has been reported that about 4100 cases of chronic form of compartment syndrome occurred between the years 2006 to 2011 [4].
Pathophysiology
Muscles of the arms and legs are separated by thick layers of tissue known as fascia. Each individual layer of fascia consists of a confined space known as the compartment. This compartment contains muscle nerves, blood vessels and tissues. All these are closely covered by the fascia. It is necessary to understand that there is no way through which fascia can expand.
As a result when pressure builds up inside a compartment, the muscles, nerves and blood vessels are compressed. When the pressure increases beyond limits, the blood flow is restricted causing permanent damage to the nerves and muscles. In such cases, if treatment is not initiated on time then the muscles unable to bear any more pressure undergo atrophy. As a result amputation of the affected limb would be the only available alternative [5].
Prevention
So far no guidelines have been given to prevent the development of compartment syndrome. However, with early diagnosis and prompt initiation of treatment the onset of complications can certainly be prevented.
Individuals with casts should be told in advance about the swelling that can develop. If such patients experience pain under the cast, then they should immediately seek medical advice.
Summary
Decrease in the blood flow due to pressure buildup in a muscle compartment limits the supply of oxygen and nutrition to the nerves and the muscle cells. Timely initiation of treatment is necessary; failure to do can cause incapacitating complications to set in. Compartment syndrome can be acute and chronic in nature. Acute form of compartment syndrome is a medical emergency requiring prompt treatment. On the other hand, the chronic form is less severe and is also known as exertional compartment syndrome [1].
Patient Information
Definition
Compartment syndrome is described as excessive increase in the pressure within a muscle compartment. The consequent buildup of pressure in the compartment can call for restricted blood flow which in turn can cause muscles and nerve damage. Compartment syndrome can be acute or chronic in nature.
Cause
The cause of pressure buildup within the muscles can be attributed to trauma resulting from injury or accidents. Chronic compartment syndrome is more common among athletes and occurs due to repetitive activities and carrying out heavy exercises. In such cases, the pressure increases in the compartment only during such activities. The body parts most commonly affected by this condition include the forearm and the lower leg. However, in some instances it can also affect the thigh, upper arm, hand and foot.
Symptoms
One of the most classical symptoms of compartment syndrome includes development of severe pain in the affected area that gets worse and does not fade away with medications. In addition, individuals also experience feeling of numbness, burning or tingling sensation in the affected area. It also becomes difficult to remove the part of the limb that is affected.
Diagnosis
In most cases physical examination is enough to diagnose the condition. However, many a times analyzing the creatine phosphokinase levels and evaluating kidney functioning is also required.
Treatment
Surgery is often the method of choice to treat compartment syndrome. It is employed to prevent permanent damage to the affected area. Pain relieving medications are also administered depending on the patient’s profile.
References
- Matsen FA 3rd. Compartmental syndrome. An unified concept. Clin Orthop Relat Res. Nov-Dec 1975;8-14.
- Black KP, Schultz TK, Cheung NL. Compartment syndromes in athletes. Clin Sports Med 1990; 9:471
- Sheridan GW, Matsen FA 3rd. Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am. Jan 1976;58(1):112-5.
- Waterman BR, Liu J, Newcomb R, et al. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med 2013; 41:2545.
- Rorabeck CH, Macnab I. The pathophysiology of the anterior tibial compartmental syndrome. Clin Orthop Relat Res. Nov-Dec 1975;52-7
- Almdahl SM, Samdal F. Fasciotomy for chronic compartment syndrome. Acta Orthop Scand 1989; 60:210.
- Hutchinson MR, Ireland ML. Common compartment syndromes in athletes. Treatment and rehabilitation.Sports Med. Mar 1994;17(3):200-8.
- Barnes M. Diagnosis and management of chronic compartment syndromes: a review of the literature. Br J Sports Med 1997; 31:21.
- Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med 1993; 21:811.
- Liem NR, Bourque PR, Michaud C. Acute exertional compartment syndrome in the setting of anabolic steroids: an unusual cause of bilateral footdrop. Muscle Nerve. Jul 2005;32(1):113-7.