Updated: 3/3/2022

Leg Compartment Syndrome

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  • 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
          • fractures (69% of cases)
          • crush injuries
          • contusions
          • gunshot wounds
        • tight casts, dressings, or external wrappings
        • extravasation of IV infusion
        • burns
        • postischemic swelling
        • bleeding disorders
        • arterial injury
      • pathoanatomy
        • cascade of events includes
          • local trauma and soft tissue destruction
          • bleeding and edema
          • increased interstitial pressure
          • vascular occlusion (decreased venous outflow relative to arterial inflow)
          • myoneural ischemia
    • Risk factors
      • diaphyseal fractures
      • young age (highest prevalence in 12-19 year olds)
  • Anatomy
    • 4 compartments of the leg
      • anterior compartment
        • function
          • dorsiflexion of foot and ankle
        • muscles
          • tibialis anterior
          • extensor hallucis longus
          • extensor digitorum longus
          • peroneus tertius
      • lateral compartment
        • function
          • plantarflexion and eversion of foot
        • muscles
          • peroneus longus
          • peroneus brevis
        • isolated lateral compartment syndrome would only affect superficial peroneal nerve
      • deep posterior compartment
        • function
          • plantarflexion and inversion of foot
        • muscles
          • tibialis posterior
          • flexor digitorum longus
          • flexor hallucis longus
      • superficial posterior compartment
        • function
          • mainly plantarflexion of foot and ankle
        • muscles
          • gastrocnemius
          • soleus
          • plantaris
  • 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
          • entry point
            • 1cm lateral to anterior border of tibia within 5cm of fracture site if possible
          • needle should be perpendicular to skin
        • deep posterior compartment
          • entry point
            • just posterior to the medial border of tibia
          • advance needle perpendicular to skin towards fibula
        • lateral compartment
          • entry point
            • just anterior to the posterior border of fibula
        • superficial posterior
          • entry point
            • middle of calf within 5 cm of fracture site if possible
  • Diagnosis
    • Clinical
      • based primarily on physical exam in patient with intact mental status
  • Treatment
    • Nonoperative
      • observation
        • indications
          • diastolic differential pressure (delta p) is > 30
          • presentation not consistent with compartment syndrome
      • bi-valving the cast and loosening circumferential dressings
        • indications
          • initial treatment for swelling or pain that is NOT compartment syndrome
        • 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
          • clinical presentation consistent with compartment syndrome
          • compartment pressures within 30 mm Hg of diastolic blood pressure (delta p)
            • intraoperatively, diastolic blood pressure may be decreased from anesthesia
              • must compare intra-operative measurement to pre-operative diastolic pressure
              • attempt to restore systemic blood pressure prior to measurement
        • contraindications
          • missed compartment syndrome
    • Special considerations
      • pediatrics
        • children are unable to verbalize feelings
          • if suspicion, then perform compartment pressure measurement under sedation
      • hemophiliacs
        • give Factor VIII replacement before measuring compartment pressures
  • Techniques
    • Emergent fasciotomy of all four compartments
      • dual medial-lateral incision
        • approach
          • two 15-18cm vertical incisions separated by 8cm skin bridge
            • anterolateral incision
            • posteromedial incision
        • technique
          • anterolateral incision
            • identify and protect the superficial peroneal nerve
            • fasciotomy of anterior compartment performed 1cm in front of intermuscular septum
            • fasciotomy of lateral compartment performed 1cm behind intermuscular septum
          • posteromedial incision
            • protect saphenous vein and nerve
            • incise superficial posterior compartment
            • detach soleal bridge from back of tibia to adequately decompress deep posterior compartment
        • post-operative
          • dressing changes followed by delayed primary closure or skin grafting at 3-7 days post decompression
        • pros
          • easy to perform
          • excellent exposure
        • cons
          • requires two incisions
      • single lateral incision
        • approach
          • single lateral incision from head of fibula to ankle along line of fibula
        • technique
          • identify superficial peroneal nerve
          • perform anterior compartment fasciotomy 1cm anterior to the intermuscular septum
          • perform lateral compartment fasciotomy 1cm posterior to the intermuscular septum
          • identify and perform fasciotomy on superficial posterior compartment
          • enter interval between superficial posterior and lateral compartment
          • reach deep posterior compartment by following interosseous membrane from the posterior aspect of fibula and releasing compartment from this membrane
            • common peroneal nerve at risk with proximal dissection
        • pros
          • single incision
        • cons
          • decreased exposure

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Questions (27)
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(OBQ18.243) A 25-year-old male sustains the injury depicted in Figure A. He is splinted in the field, but on arrival to the emergency room, he complains of painful "tightness" around the leg and severe uncontrolled pain despite maximum dose narcotics. His pain is exacerbated when the toes and ankle are passively stretched in flexion and extension. What is the most appropriate next step in treatment?

QID: 213139
FIGURES:

External fixation with serial doppler examinations

1%

(16/2290)

Intramedullary nailing

0%

(9/2290)

Open reduction internal fixation using plates and screws

0%

(9/2290)

Immediate 2-compartment fasciotomies and external fixation

2%

(57/2290)

Immediate 4-compartment fasciotomies and external fixation

95%

(2178/2290)

L 1 A

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(OBQ18.254) A 24-year-old male is brought to the ED after an MVC. He is found to have a closed comminuted segmental fibula fracture after a prolonged extraction from the vehicle. Several hours after arrival, the patient reports increasing pain and is noted to have an exacerbation of his pain with passive stretching of the ankle. He has a heart rate of 103 and a blood pressure of 141/87. Compartment pressures are obtained and are 27 mmHg in the anterior compartment, 47 mmHg in the lateral compartment, 28 mmHg in the superficial posterior compartment, and 27 mmHg in the deep posterior compartment. Which of the following correctly describes the initial pathophysiology of compartment syndrome and the neurologic deficit that would likely occur in this patient if left untreated?

QID: 213150

Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the first webspace

4%

(77/1784)

Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes

10%

(184/1784)

Decreased arterial inflow; inability to dorsiflex his ankle

3%

(50/1784)

Decreased venous outflow; decreased sensation on the dorsum of his foot involving the first webspace

18%

(318/1784)

Decreased venous outflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes

63%

(1124/1784)

N/A A

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(OBQ15.111.1) You are called to evaluate a 45-year-old male in the ED who was in a motor vehicle accident prior to arrival. EMS reported a prolonged extrication and GCS of 6 on scene, which required a field intubation. He has obvious deformity and crepitus of his left leg, with radiographs seen in Figure A. The ED physician reports an increase in soft tissue swelling and firmness of the leg. You decide to measure the patient's compartments given clinical concern for compartment syndrome. Which of the following is true of intracompartmental pressure measurements?

QID: 216658
FIGURES:

Interobserver reliability is poor

45%

(381/851)

Should be obtained remote to the zone of injury

18%

(152/851)

Should always be obtained to objectively confirm clinical suspicion for compartment syndrome

5%

(41/851)

Have high specificity for diagnosis of compartment syndrome when absolute pressures exceed 20 mmHg

12%

(103/851)

Threshold for fasciotomy remains similar intraoperatively

20%

(170/851)

L 1

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(SBQ13PE.95.2) An 8-year-old boy is involved in an ATV crash. Xrays were obtained in the trauma bay after being airlifted to your facility, shown in Figures A. On the day of presentation, you perform the treatment shown in the figure B. On postoperative day 1, the patient states his pain is controlled, however, you find that his calf is tense, his foot is cool and has diminished pulses compared to the contralateral extremity. What is the best next step of the options below?

QID: 214226
FIGURES:

Remove your fixation and perform repeat reduction

4%

(61/1726)

Measure leg compartment pressures

52%

(899/1726)

Request vascular consultation

7%

(116/1726)

Measure ankle-brachial index (ABI)

33%

(561/1726)

Duplex ultrasound evaluation

5%

(79/1726)

L 4 D

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(OBQ12.28) A 35-year-old male sustains a closed tibial shaft fracture after falling from 12 feet. Which of the following measurements would be concerning for an evolving compartment syndrome?

QID: 4388

Intraoperative anterior compartment measurement of 29, with preoperative diastolic pressure 58

75%

(5484/7341)

Preoperative anterior compartment measurement of 25, with preoperative diastolic pressure of 60

7%

(483/7341)

Intraoperative anterior compartment measurement of 25, with intraoperative diastolic pressure of 54

14%

(1011/7341)

Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72

2%

(176/7341)

Preoperative anterior compartment measurement of 22, with mean arterial pressure of 70

2%

(130/7341)

L 2 A

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(OBQ11.75) A 28-year-old male sustains a midshaft fibula fracture after being kicked during a karate tournament and develops compartment syndrome isolated to the lateral compartment of his leg. If left untreated, which of the following sensory or motor deficits would be expected?

QID: 3498

Decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes

80%

(2313/2904)

Inability to plantar flex the ankle

1%

(37/2904)

Decreased sensation on the dorsum of his foot involving the first webspace

11%

(330/2904)

Inability to dorsiflex the ankle

6%

(160/2904)

Inability to abduct his toes

2%

(52/2904)

L 1 C

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(OBQ10.23) During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?

QID: 3111

Superficial posterior

1%

(37/3737)

Deep posterior

97%

(3643/3737)

Lateral

1%

(24/3737)

Anterior

1%

(22/3737)

Mobile wad

0%

(5/3737)

L 1 C

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(OBQ08.145) A 35-year-old female presents to the emergency room after a motor vehicle collision where her leg was pinned under the car for over 30 minutes. A clinical photo and radiographs are shown. Which of the following is the most accurate way to diagnose compartment syndrome?

QID: 531
FIGURES:

surgeon's palpation of the leg compartments

6%

(62/1023)

paresthesias in her foot

1%

(11/1023)

diastolic blood pressure minus intra-compartmental pressure is less than 30 mmHg

79%

(812/1023)

diastolic blood pressure minus intra-compartmental pressure is greater than 30 mmHg

10%

(101/1023)

intra-compartmental pressure measurement of 25 mmHg

3%

(31/1023)

L 2 B

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(OBQ08.170) A 32-year-old male sustains the injury seen in Figure A. His blood pressure preoperatively was 132/84. After closed reduction and placement of an intramedullary nail, his intraoperative leg compartment pressures are measured, with the highest being 28 mmHg. His blood pressure at this time is 84/57. What is the next appropriate step?

QID: 556
FIGURES:

Immediate four compartment fasciotomy

25%

(269/1084)

Fasciotomy of the highest compartment(s)

2%

(26/1084)

Removal of the nail and placement of an external fixator

1%

(6/1084)

Repeat evaluation in recovery room

68%

(734/1084)

Addition of pressors to anesthesia

4%

(47/1084)

L 1 B

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(OBQ07.256) Which of the following structures is at risk during proximal dissection of a single lateral perifibular approach for compartment syndrome of the leg?

QID: 917

Common peroneal nerve

48%

(1134/2340)

Superficial peroneal nerve

43%

(1011/2340)

Deep peroneal nerve

6%

(144/2340)

Anterior tibial artery

1%

(24/2340)

Lateral inferior genicular artery

1%

(20/2340)

L 4 D

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(OBQ07.105) A 10-year-old girl is treated for a tibia/fibula fracture with a long leg cast. The on-call resident is called to evaluate the patient for increasing pain medicine requirements and tingling in her foot. Examination of the cast reveals that the ankle has been immobilized in 10 degrees of dorsiflexion. What ankle position results in the safest compartment pressures in a casted lower leg?

QID: 766

40-50 degrees of plantar flexion

2%

(28/1691)

10-20 degrees of ankle dorsiflexion

1%

(25/1691)

Neutral to 30 degrees of plantar flexion

73%

(1230/1691)

Neutral to 10 degrees of dorsiflexion

13%

(222/1691)

Ankle position has no effect on calf compartment pressure

11%

(179/1691)

L 2 C

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(OBQ06.129) Increasing the oxygen gradient for diffusion is the primary mechanism of action for which of the following methods of treatment of lower extremity trauma?

QID: 315

Open fasciotomy

4%

(40/1099)

Percutaneous fasciotomy

0%

(1/1099)

High-dose anti-inflammatories

1%

(8/1099)

Hyperbaric oxygen therapy

89%

(982/1099)

Negative pressure wound therapy

6%

(66/1099)

L 1 D

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(OBQ06.97) Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?

QID: 208

pulselessness

1%

(24/1953)

pallor

1%

(12/1953)

paresthesia

1%

(25/1953)

paralysis

1%

(10/1953)

increasing analgesia requirement

96%

(1869/1953)

L 1 C

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(OBQ05.191) An 11-year-old child has a tibia-fibula fracture following a fall from a swing. The fracture is reduced and placed in a long leg splint in the emergency room. What is considered the earliest sign or symptom of a developing compartment syndrome of the leg?

QID: 1077

pain out of proportion to injury

97%

(2122/2195)

pale appearance of the foot

0%

(7/2195)

loss of the ability to move the toes

1%

(15/2195)

decreased sensation in the foot

2%

(37/2195)

decreased pulses in the foot

0%

(7/2195)

L 1 C

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(SBQ04PE.1) A 6-year-old boy with progressive bilateral genu varum undergoes the surgeries shown in Figure A. On postoperative rounds later that day, the patient appears sedated after several doses of pain medication. His toes are pink with brisk capillary refill however, passive motion of his toes causes pain. Among the answer choices listed, what is the best management strategy for this child?

QID: 2186
FIGURES:

Elevate his legs and reevaluate on morning rounds

1%

(6/896)

Adjust his pain medication to accommodate for his increasing pain

1%

(6/896)

Administer a muscle relaxant for leg spasms

0%

(2/896)

Cast removal and measurement of compartment pressures with a standard device

95%

(852/896)

Examine the cast for areas of constriction and reevaluate in the morning

2%

(21/896)

L 1 C

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(OBQ04.87) All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT:

QID: 1192

Increasing analgesic requirement is an important indicator for the diagnosis of compartment syndrome in children

6%

(71/1189)

Duration of compartment syndrome prior to treatment is the most important variable in determining the outcome

7%

(80/1189)

Mechanism of injury is the best predictor of compartment syndrome development

59%

(706/1189)

Traditional hallmarks of adult compartment syndrome may be more challenging to detect in pediatric compartment syndrome

4%

(48/1189)

Careful patient positioning and the use of prophylactic fasciotomy are methods of preventing compartment syndrome

23%

(274/1189)

L 1 C

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EXPERT COMMENTS (45)
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