Compartment syndrome occurs when volume (usually edema and/or blood) accumulates in a confined osseofascial space to the extent that delivery of oxygen to tissues is compromised. It is most common with orthopedic trauma (40% tibial shaft, 18% forearm, also femur and ankle) although 23% are caused by soft tissue trauma with no fracture. Compartment syndromes have also been associated with burns, reperfusion injury, prolonged limb compression, and even drug overdose. If untreated, compartment syndrome can lead to permanent neurologic damage, muscular damage, and loss of limb.
The classic signs are the five p’s – pulselessness, pallor, paralysis, paresthesia, and pain (often out of proportion to the clinical situation) By the time a patient is experiencing the 6 P’s, the risk of morbidity after fasciotomy is already very high, and ischemic injury is likely already be occurring. Peripheral compartment syndrome should be suspected early in cases where pain is out of proportion to the amount of surgical trauma. Pain with passive stretching, or paresthesia can be early signs of compartment syndrome.
It is often claimed that regional anesthesia should not be performed in patients at risk for compartment syndrome, as it may theoretically mask the presenting symptom. This assertion is not, however, supported by any data, and in fact there are data to suggest that regional (epidural) anesthesia does not mask the presenting signs/symptoms of a compartment syndrome.
In reality, excruciating pain is a late/too late symptom and should not be thought of as a “presenting” symptom. The key to early diagnosis is appropriate monitoring of at-risk patients, repeated evaluation of perfusion and tissue oxygenation, monitoring of intracompartmental pressure (although non-invasive monitoring is not 100% reliable), as well as certain precautions (e.g., avoidance of closed plaster casts). In special cases, invasive intracompartmental pressure should be monitored.
Treatment is via fasciotomy and is emergent (usually attempted with pressures 20-30 mm Hg below diastolic pressure).
- Diagnosis: Five P’s (pulselessness, pallor, paralysis, paresthesia, and pain)
- Risk Factors: orthopedic trauma, most commonly tibia fractures
- Regional Anesthesia: controversial but data do NOT support witholding (Llewellyn 2007)
- Invasive Monitoring: transduce angiocatheter in fascia
- Treatment: fasciotomy, usually attempted with pressures 20-30 mm Hg below DBP
- N Llewellyn, A Moriarty The national pediatric epidural audit. Paediatr Anaesth: 2007, 17(6);520-33