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Introduction
  •  Devastating condition where an osseofascial 
    compartment pressure rises to a level that decreases perfusion
  • May lead to irreversible muscle and nerve damage
  • May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
    • leg
    • forearm
    • hand
    • foot
    • thigh (details below)
    • buttock
    • shoulder
    • paraspinous muscles
  • Pathophysiology
    • local trauma and soft tissue destruction > 
    • bleeding and edema > 
    • increased interstitial pressure > 
    • vascular occlusion > 
    • myoneural ischemia
  • Causes
    • trauma (most common)
      • ipsilateral femur fractures
        • increased incidence with open fractures 
      • crush injuries
      • contusions
      • gunshot wounds
    • tight casts, dressings, or external wrappings
    • extravasation of IV infusion
    • burns
    • postischemic swelling
    • bleeding disorders
    • arterial injury
Anatomy
  • 3 thigh compartments  
    • anterior compartment
      • muscles
        • quadriceps 
        • sartorious 
      • nerves
        • femoral nerve
    • posterior compartment
      • muscles
        • hamstrings
      • nerves
        • sciatic nerve
    • adductor compartment
      • muscles
        • adductors
      • nerves
        • obturator nerve
Presentation
  • Symptoms
    • pain out of proportion to clinical situation is usually 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
        • must test each compartment separately
          • anterior compartment
            • pain with passive flexion of knee
          • posterior compartment
            • pain with passive extension of knee
          • medial compartment
            • pain with passive abduction of hip
    • paraesthesia 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
Evaluation 
  • Diagnosis
    • based primarily on physical exam in patient with intact mental status
  • Radiographs
    • obtain to rule-out fracture
  • 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 or area of maximal swelling
      • must test each compartment separately
Treatment
  • Nonoperative
    • observation
      • indications
        • delta p > 30, and
        • presentation not consistent with compartment syndrome
  • Operative
    • emergent fasciotomy of all affected compartments
      • indications
        • clinical presentation consistent with compartment syndrome
        • compartment pressures with absolute value of 30-45 mm Hg
        • 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
      • contraindications
        • missed compartment syndrome
Surgical Techniques
  • Thigh fasciotomies   
    •  approach
      • anterolateral incision over length of thigh
    • technique
      • single incision technique for anterior and posterior compartments
      • incise fascia lata
      • expose and decompress anterior compartment
      • retract vastus lateralis medially to expose lateral intermuscular septum
      • incise lateral intermuscular septum to decompress posterior compartment
      • may add medial incision for decompression of adductor compartment
Complications
  • Associated with significant long-term morbidity
    • over 50% will experience functional deficits including
      • pain
      • decreased knee flexion
      • myositis ossificans
      • sensory deficits
      • decreased strength
 
 

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