Compartmental Syndromes.
Edited By: Frederick A. Matsen III, M.D., Winston J. Warme, MD
Last updated Thursday, February 10, 2005
About compartmental syndromes
A compartmental syndrome is a condition in which increased pressure
within a limited space compromises the circulation and function of the
tissues within that space. This condition is a cause of major loss of
function, limb and even life. It can result from trauma, prolonged
recumbancy (in surgery or resulting from drugs or alcohol), or physical
activity. It is common enough to affect thousands of individuals each
year, yet rare enough that each physician may encounter it only once or
twice during his or her career.Summary Compartmental syndromes challenge even the best clinicians. These
syndromes occur when locally increased tissue pressure compromises
local circulation and neuromuscular function. The incidence of
compartmental syndromes is rising along with the frequency of their
various etiologies: extremity trauma, limb ischemia, intensive use of
muscles, extremity surgery, and drug and alcohol abuse. Despite this
increase in frequency, the compartmental syndrome remains sufficiently
uncommon in the experience of the average practitioner that he may be
unfamiliar with its diagnosis and management. Because prompt treatment
of compartmental syndromes is essential, the consequences of this
unfamiliarity may be serious. Even to those most familiar with them,
compartmental syndromes pose major problems in pathogenesis, diagnosis,
and treatment. For example, the precise effect of increased tissue
pressure on the microcirculation-the key to understanding compartmental
syndromes-remains a matter of considerable conjecture.
The clinical diagnosis of a compartmental syndrome is frequently
made difficult by the fact that other conditions may produce similar
symptoms and signs. Although new diagnostic methods, such as tissue
pressure measurement, have been described, they have failed to
completely resolve these problems of differential diagnosis. This
failure is a result of practical problems in the application of these
techniques and in the interpretation of their results. Thus, the
physician is called upon to synthesize all the available information in
arriving at the correct diagnosis.
Adequate treatment of compartmental syndromes requires the wide
opening of all potentially affected compartments. Unfortunately, the
institution of this treatment is often delayed in the hope that the
compartmental syndrome will resolve spontaneously. Even if prompt
surgery is performed, the functional result may be compromised by an
incomplete decompression carried out in the hope of a superior cosmetic
result. Special problems may be presented by the surgical wound after
decompression and by fractures that are associated with compartmental
syndromes. Compartmental syndromes may give rise to significant
complications that include infection and myoglobinuric renal failure.
Definition of the compartmental syndrome There is a vital need for new organization of the literature on
compartmental syndromes. Attempts to locate the relevant articles are
frustrated by the lack of an appropriate indexing system. For example,
the Index Medicus has entries only for "Volkmann's ischemia" and
"anterior compartment syndrome"; thus, it is difficult to know where to
locate information on compartmental syndromes in other locations.
Furthermore, in the Journal of Bone and Joint Surgery Quinquennial
Index (1973-1977), all compartmental syndromes are listed under
"Volkmann's ischemia." Finally, Sheridan and Matsen's classic article
"Fasciotomy in the treatment of the acute compartment syndrome"1 is
listed under the following headings in the Medline system: acute
disease, adolescents, adults, aged, child, fascia/ surgery, female,
human, male, middle age, neuromuscular disease/ surgery, postoperative
complications/etiology, syndrome, and time factors. Thus, this
important article could not be located by a search that requests
articles dealing with compartmental syndromes, tissue pressure, or even
ischemia.
A further example of the confusion resulting from the lack of
organized nomenclature may be found in the 1979 American Academy of
Orthopaedic Surgeons Orthopaedic In-Training Examination (page 5,
question T3). The question concerns the early signs of "impending
Volkmann's ischemic contracture," and for the answer we are referred to
an article on "anterior tibial compartment syndrome." These two terms
bear little apparent relation to one another.
Use of the literature is confused even further by a plethora of
other names used to refer to the compromise of local circulation by
increased tissue pressure.
Being aware of the problems with the existing nomenclature, I
proposed a system for referring to those conditions in which
pressure-induced circulatory compromise plays a central role.2l This
proposed nomenclature is based on the following definition: A
compartmental syndrome is a condition in which increased pressure
within a limited space compromises the circulation and function of the
tissues within that space. This definition brings out the four
requisites of a compartmental syndrome: a limiting envelope within
which increased tissue pressure produces reduced tissue circulation
that results in abnormalities of neuromuscular function.
My sole purpose in using the term "compartmental syndrome" rather
than "compartment syndrome" is to indicate that I employ the foregoing
definition as opposed to the multiple vague definitions associated with
the term "compartment syndrome." The definition permits the development
of a "unified concept," which is founded on the premise that increased
tissue pressure produces similar circulatory and functional effects
wherever the process is located and whatever the initiating cause may
be. 2l For example, increased tissue pressure in the forearm from a
fracture and increased tissue pressure in the leg from intensive use of
muscles are seen to produce similar physiological effects and clinical
manifestations. Furthermore, the treatment of these two compartmental
syndromes is the same: restitution of local blood flow by decompression
of the tissues within the compartment.
This unified concept permits us to discuss a wide variety of
compartmental syndromes together as a family group, distinguishing
among the members only as their individual peculiarities require.
Specific etiologies may be indicated, e.g., "compartmental syndromes
due to intensive use of muscles." Location may also be specified, e.g.,
"deep posterior compartmental syndromes of the leg." Thus, the
definition of the compartmental syndrome and the unified concept
provide an organized system of nomenclature for referring either to all
of these conditions as a group or to any member of that group. Surgery for Compartmental Syndromes at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-BONE (2663) to make an appointment.
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