Compartmental Syndromes.
Edited By: Winston J. Warme, MD, Frederick A. Matsen III, M.D.
Last updated Thursday, February 10, 2005
Clinical approach
A standard clinical approach to the patient at risk for a compartmental
syndrome is of value in the prevention, early detection, and treatment
of acute compartmental syndromes.Minimizing morbidity The following approach is proposed to help minimize the morbidity from compartmental syndromes.
- Prevent compartmental syndromes whenever possible. Effective
measures may include prophylactic fasciotomy, minimization of soft
tissue trauma and ischemia, and avoidance of tight circumferential
dressings.
- Identify patients at risk. All patients with the potential for
significantly increased intracompartmental pressure should be
considered to be at risk for a compartmental syndrome. The common
causes of increased intracompartmental pressure are listed in Chapter
5. Patients with these conditions require close observation for early
evidence of a compartmental syndrome.
- Perform a thorough initial examination and document it well. The
initial examination may serve two functions: (a) it helps with the
diagnosis or exclusion of a compartmental syndrome at the time this
examination is made, and (b) it establishes the base line for
determining subsequent changes in the patient's condition. For example,
any deterioration of neuromuscular function after the initial
examination would strongly suggest a compartmental syndrome rather than
nerve or muscle damage occurring at the time of the initial injury. The
patient's chart should reflect the date, time, and name of the examiner
as well as the following information about the compartments at risk:
(a) the patient's complaints of pain, (b) the strength of the muscles
in the compartment, (c) the patient's response to passive stretch of
the muscles in the compartment, (d) the sensation in the distribution
of nerves coursing through the compartment, and (e) the tenseness of
the compartmental envelope.
-
Admit patients at significant risk for compartmental syndromes. The
frequent examinations that are necessary to permit early diagnosis and
treatment are only possible when the patient has been admitted to the
hospital. Care should be taken to assure that those observing the
patient understand the proper techniques for examination. Uninstructed,
inexperienced examiners may fail to test specifically for toe extension
and fall into the "wiggle your toes" trap (see Chapter 7). They may
also be unaware of the important sensory area of the deep peroneal
nerve in the first web space and overlook the presence of hypesthesia
in that location. When the responsibility of the examination is passed
from one individual to another, for example, at the nurses' change of
shift, it is very useful for the person coming on duty and the person
leaving to perform an examination together; this joint effort
eliminates any confusion about the current status of the patient or the
technique of the examination.
- Remove circumferential dressings early. The appearance of pain out
of proportion to what is expected from the clinical situation, deficits
in motor or sensory function, or pain on passive muscle stretch may
well be evidence of a compartmental syndrome. To assure that increased
tissue pressure is not resulting from tight circumferential dressings,
casts should be bivalved (see Chapter 8); one-half of the cast is
removed, and all soft dressings are split to the skin. Frequently,
simply splitting the cast does not provide adequate decompression. The
consequences of loss of fracture position are insignificant compared
with those of a compartmental syndrome.
- Maximize local arterial pressure, especially if there is evidence
of compartmental ischemia. Systemic hypotension should be treated;
local hypotension should be minimized by placing the limb at the level
of the heart.
- Utilize tissue pressure measurement, particularly if the clinical
evaluation is incomplete or confusing. Tissue pressure measurement is a
useful adjunct to the clinical evaluation of patients at risk for
compartmental syndromes.
- If surgical decompression is indicated, promptly and completely
open all potentially limiting envelopes. The use of limited skin
incisions, primary closure of the skin, or failure to open all four
compartments of the leg may permit the recurrence of compartmental
syndromes after surgical decompression.
- Minimize operative debridement. The potential of nerve and muscle
for repair or reconstruction after an ischemic insult indicates that
only obviously nonviable tissues should be removed at the time of
surgical decompression.
- Consider skeletal fixation of unstable fractures associated with compartmental syndromes.
- Delay skin closure until three to five days after surgical
decompression. At this time, delayed primary closure, the application
of meshed skin grafts, or progressive wound edge approximation may
usually be safely instituted. If questionably viable tissue is present,
closure should be further delayed.
- Minimize contractures by appropriate splinting and range of motion exercises.
- Look for myoglobinuria and other systemic consequences of muscle
necrosis. If myoglobinuria is suspected, maintain a high urinary output
to lessen the nephrotoxic effect.
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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