summary Leg Compartment Syndrome is a devastating lower extremity condition where the osseofascial compartment pressure rises to a level that decreases perfusion to the leg and may lead to irreversible muscle and neurovascular damage. Diagnosis is made with the presence of severe and progressive leg pain that worsens with passive ankle motion. Firmness and decreased compressibility of the compartments is often present. Needle compartment pressures are diagnostic in cases of inconclusive physical exam findings and in sedated patients. Treatment is usually emergent fasciotomies of all 4 compartments. Epidemiology Anatomic location compartment syndrome may occur anywhere that skeletal muscle is surrounded by fascia, but most commonly leg (details below) forearm hand foot thigh buttock shoulder paraspinous muscles Etiology Pathophysiology etiology trauma login to view 4 more bullets tight casts, dressings, or external wrappings extravasation of IV infusion burns postischemic swelling bleeding disorders arterial injury pathoanatomy cascade of events includes login to view 5 more bullets Risk factors diaphyseal fractures young age (highest prevalence in 12-19 year olds) open fracture segmental or comminuted fracture pattern higher BMI (in pediatric patients) Anatomy 4 compartments of the leg anterior compartment function login to view 1 more bullet muscles login to view 4 more bullets lateral compartment function login to view 1 more bullet muscles login to view 2 more bullets isolated lateral compartment syndrome would only affect superficial peroneal nerve deep posterior compartment function login to view 1 more bullet muscles login to view 3 more bullets superficial posterior compartment function login to view 1 more bullet muscles login to view 3 more bullets Presentation Symptoms pain out of proportion to the clinical situation is usually the first symptom may be absent in cases of nerve damage pain is difficult to assess in a polytrauma patient and impossible to assess in a sedated patient difficult to assess in children (unable to verbalize) Physical exam pain w/ passive stretch is most sensitive finding prior to onset of ischemia paresthesia and hypoesthesia indicative of nerve ischemia in affected compartment paralysis late finding full recovery is rare in this case palpable swelling peripheral pulses absent late finding amputation usually inevitable in this case Imaging Radiographs obtain to rule-out fracture Studies Compartment pressure measurements indications polytrauma patients patient not alert/unreliable inconclusive physical exam findings relative contraindication unequivocally positive clinical findings should prompt emergent operative intervention without need for compartment measurements technique should be performed within 5cm of fracture site low rates of interobserver reliability have been noted with measurements anterior compartment login to view 3 more bullets deep posterior compartment login to view 3 more bullets lateral compartment login to view 2 more bullets superficial posterior login to view 2 more bullets Diagnosis Clinical based primarily on physical exam in patient with intact mental status continuous intramuscular compartment pressure monitoring is highly sensitive and specific for the diagnosis of acute compartment syndrome in obtunded or intubated patients usually performed in the anterior compartment of the lower leg higher spatial variations in compartment pressure measurements are found: login to view 2 more bullets Treatment Nonoperative observation indications login to view 2 more bullets bi-valving the cast and loosening circumferential dressings indications login to view 1 more bullet splinting the ankle between neutral and resting plantar flexion (37 deg) can also decrease intracompartmental pressures hyperbaric oxygen therapy works by increasing the oxygen diffusion gradient Operative emergent fasciotomy of all four compartments indications login to view 5 more bullets contraindications login to view 1 more bullet Special considerations pediatrics children are unable to verbalize feelings login to view 1 more bullet hemophiliacs give Factor VIII replacement before measuring compartment pressures Techniques Emergent fasciotomy of all four compartments dual medial-lateral incision approach login to view 3 more bullets technique login to view 8 more bullets post-operative login to view 1 more bullet pros login to view 2 more bullets cons login to view 1 more bullet single lateral incision approach login to view 1 more bullet technique login to view 7 more bullets pros login to view 1 more bullet cons login to view 1 more bullet