Compartmental Syndromes.
Edited By: Winston J. Warme, MD, Frederick A. Matsen III, M.D.
Last updated Thursday, February 10, 2005
TreatmentDetails about treatment The objective of treatment of a compartmental syndrome is to
minimize deficits in neurological function by promptly restoring local
blood flow, usually by surgical decompression.
Certain nonoperative measures may be effective, such as eliminating external envelopes and maintaining local arterial pressure.
Vasodilator drugs or sympathetic blocks appear to be ineffective in
the treatment of compartmental syndromes, probably because in this
condition maximal local vasodilatation is already present.
Surgical decompression of all limiting envelopes is usually
indicated in the presence of (a) a characteristic clinical picture of a
compartmental syndrome, or (b) an ambiguous clinical picture in the
presence of a measured tissue pressure in excess of 40 mm Hg, provided
the patient has a normal pressure tolerance.
Only obviously nonviable tissue is debrided at the time of surgical decompression.
The skin is left open after surgical decompression to prevent it
from becoming a limiting envelope during the anticipated period of
postischemic swelling.
Skin closure may usually be accomplished three to five days after
surgical decompression by direct suture or meshed skin graft. The skin
may also be progressively closed over the ensuing 10 to 14 days with
suture or sterile paper tape.
Skeletal fixation is a useful adjunct to management of the limb when
a compartmental syndrome is associated with an unstable fracture.
Increased tissue pressure is the pathogenic factor in the
compartmental syndrome. Thus, the primary goal in treating this
condition is the prompt lowering of tissue pressure to normal levels. A
definitive reduction in tissue pressure is accomplished by the complete
opening of all envelopes surrounding the affected tissue. This opening
must not only decompress the contents of the compartment, but also
accommodate any postischemic swelling occurring after the decompression
procedure. If significant postischemic swelling occurs within
incompletely opened envelopes, a "rebound" compartmental syndrome may
occur.
Movies
Opening external envelopes Because tissue pressure may be increased as a result of tight external
envelopes (e.g., dressings and casts), it is essential that such
envelopes be eliminated at the first evidence of a compartmental
syndrome. Pliable dressings are simply divided down to the level of the
skin. Rigid dressings such as casts should be bivalved so that the
anterior half may be completely removed. A single cut through a cast,
even if the cast is spread and wedged open, often does not sufficiently
increase the volume of the cast envelope. Although removal of the front
half of a cast may jeopardize the reduction of a fracture, restoration
of local circulation must take precedence. Fracture reduction can
usually be regained; however, local circulatory insufficiency may
produce permanent, deleterious effects.Maintaining local arterial pressure Before operative methods for reducing tissue pressure are discussed,
the importance of maintaining local arterial pressure should be
considered. Local arterial hypotension reduces the tissue's pressure
tolerance and increases the adverse effects of a given tissue pressure
(see Chapter 4). This is true whether the local arterial pressure has
been reduced by shock, peripheral vascular disease, or elevation of the
limb above the heart. Thus, treatment of systemic hypotension and
avoidance of limb elevation are important for the maintenance of local
arterial pressure and in the management of compartmental syndromes.
Although it may seem that vasodilator drugs or sympathetic blocks
might also be of benefit in improving local circulation, the
ineffectiveness of these treatments has been revealed by clinical
experience Apparently, the local circulatory insufficiency in a
compartmental syndrome is such a potent stimulus for vasodilatation
that the elimination of sympathetic tone does not additionally augment
local blood flow.
Indications for surgical decompression If the release of all external envelopes and optimization of local
arterial pressure fail to eliminate the compartmental syndrome, prompt
surgical decompression must be considered. Rigid indications for
surgical decompression are difficult to establish; each patient and
each compartmental syndrome has an individuality that affects the way
in which they are managed. In general, however, surgical decompression
is indicated in the presence of:
- Significant deficits in neuromuscular function related to increased
tissue pressure. The term "significant deficits" refers to any
functional losses that would not be acceptable in the end result. The
presence of increased tissue pressure may be detected by palpation of
the compartment or by measurement of intracompartmental pressure.
- An ambiguous clinical picture with a tissue pressure above 40 mm Hg
in a patient expected to have a normal pressure tolerance. Forty
millimeters of mercury is an empirically derived figure based on our
experience with prospective monitoring of tissue pressure in patients
at risk for compartmental syndromes (see Chapter 4). This value is not
proposed as a "critical" pressure applicable to all patients. Patients
with peripheral vascular disease, patients in shock, and patients with
elevated limbs are expected to have a diminished pressure tolerance and
may require surgical decompression at lower tissue pressures. In
arriving at the appropriate therapeutic decision, we use pressure
measurement data as an adjunct to whatever clinical information is
available: the greatest weight is given to the presence, severity, and
time-course of deficits in the function of intracompartmental nerves
and muscles.
When indicated, surgical decompression is an emergency because delay
increases the damage inflicted on intracompartmental tissue as well as
the incidence of complications (see Chapter 9). Techniques of surgical decompression Several principles are applicable to the surgical decompression of all
acute compartmental syndromes. The procedure is performed without a
tourniquet to avoid prolonging the period of ischemia and to permit the
surgeon to assess the degree to which the local circulation is restored
by decompression. Each potentially limiting envelope, including skin,
is opened over the entire length of the compartment; all muscle groups
should be soft to palpation at the end of the procedure. If muscle
tenseness remains after the skin and fascial incisions have been made,
epimysiotomy may be required to complete the surgical decompressions
The debridement of muscle is kept at a minimum at the time of surgical
decompression unless there is obvious muscle necrosis. Muscle that is
not contractile at the time of surgical decompression may still have
significant potential for recovery or reconstruction. 7, 8 Postischemic
swelling is likely to occur for several hours after surgical
decompression. 9 Therefore, the skin is left wide open to prevent the
development of a "rebound" compartmental syndrome with the skin as the
limiting envelope. Skimping on the length of the skin incision or
attempting primary skin closure to improve cosmesis is obviously poor
economy if the tissue is inadequately decompressed.Decompression of the Leg When a compartment of the leg is involved with an acute
compartmental syndrome, it is usually preferable to open all four
compartments through a single lateral incision without removing the
fibula. 11 Because all four compartments are usually exposed to the
same etiological events, involvement of one compartment may be
associated with impending involvement of the others. I have seen two
cases in which decompression of only the anterior compartment left the
patient with sequelae of an untreated deep posterior compartmental
syndrome.
Decompression of the Volar Forearm The superficial and deep volar compartments of the forearm are easily
decompressed through a longitudinal ulnar incision. 11 This procedure
is usually combined with section of the transverse carpal ligament. The
incision is readily extendible up the arm if further access to the
brachial artery is needed.Care After Surgical Decompression Sterile dressings are applied followed by splinting to hold the
extremity in a functional position. Passive stretching exercises are
instituted to maintain the range of joint motion. The patient is
returned to the operating room for wound inspection three to five days
after surgical decompression. Any obviously devitalized material is
debrided at this time, although debridement is usually not necessary
when decompression has been performed early. The wound is then closed
by suture if it is possible to approximate the skin edges without
tension. Otherwise, one may use a split-thickness skin graft 0.012 in.
thick that has been meshed at a 1:1.5 ratio. This meshed graft requires
a smaller donor area than a conventional skin graft, provides excellent
drainage, and results in satisfactory cosmesis. When optimal cosmesis
and quality of skin cover are desired, one may progressively
approximate the wound edges over 7 to 14 days with suture or sterile
paper tape. 12Skeletal fixation of associated fractures Increased tissue pressure within the fascial compartments may splint
a fractured limb by an action resembling that of an air splint. When
surgical decompression is carried out, this splinting effect is lost
and the fracture may become considerably less stable.
If a stable and satisfactory reduction cannot be accomplished,
consideration should be given to skeletal fixation of unstable
fractures associated with compartmental syndromes. External pin
fixation, plates, and intramedullary nails have been used in this
applications 11 If employed, the stabilization is performed immediately
after surgical decompression. The management of wound, limb, and
fracture is thus greatly facilitated. 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 206-598-7416 to make an appointment.
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