Time to diagnosis and treatment is the most important prognostic factors.
The diagnosis of CS depends on a high clinical suspicion and an understanding of risk factors, pathophysiology, and subtle physical findings.
Young males, with penetrating or multi-system trauma, requiring blood transfusion, with open fractures, elbow or knee dislocations, or vascular injury (arterial, venous, or combined) are at the highest risk of requiring a fasciotomy after extremity trauma. Additionally, the need for fasciotomy was related to the type of injury ranging from 2.2 % incidence for patients with closed fractures up to 41.8 % in patients with combined venous and arterial injuries. found that incidence of fasciotomy varied widely by mechanism of injury (0.9 % after motor vehicle collision to 8.6 % after a gunshot wound). In a review of 294 combat injured soldiers undergoing 494 fasciotomies, Ritenour et al. During this period, 315 fasciotomies were performed on 237 patients with 68.4 % done below the knee, 14.4 % on the forearm, and 8.9 % on the thigh. In a 10-year retrospective review of over 10,000 trauma patients sustaining extremity injury, Branco et al. Trauma is the major cause of extremity CS requiring fasciotomy. Given the consequences of missing a CS, it is important to identify the population at risk. Polytrauma or otherwise critically ill patients with low blood pressures can sustain irreversible injury at lower compartment pressures than patients with normal blood pressures, and a very high index of suspicion should be maintained in this group. Bernot and colleagues showed that tissue compromised by ischemia prior to an elevated compartment pressure has a lower threshold for metabolic deterioration and irreversible damage. Tissue previously subjected to intervals of ischemia is especially sensitive to increased pressure. Clinically, there is no precise pressure threshold and duration above which significant damage is irreversible and below which recovery is assured. Muscle shows functional changes after 2 to 4 h of ischemia with irreversible loss of function beginning at 4 to 12 h. Irreversible functional loss will occur after 12 to 24 h of total ischemia. Nerves demonstrate functional abnormalities (paresthesias and hypoesthesia) within 30 min of ischemic onset. Development of CS depends on many factors, including the duration of the pressure elevation, the metabolic rate of the tissues, vascular tone, associated soft tissue damage, and local blood pressure. As ischemia continues, irreparable damage to tissue ensues and myoneural necrosis occurs. It is imperative that all clinicians be aware of the traumatic as well as numerous non-traumatic causes (Table 1) of extremity CS, especially sepsis, massive resuscitation, and reperfusion as the diagnosis of CS in these settings is often delayed, as it is frequently not considered by many otherwise well-trained physicians.Ĭellular hypoxia is the final common pathway of all compartment syndromes. CS occurs either when compartment size is restricted or when compartment volume is increased. Groups of muscles and their associated nerves and vessels are surrounded by thick fascial layers that define the various compartments of the extremities which are of relatively fixed volume. The goal of this article is to review the pathophysiology, epidemiology, diagnosis, relevant anatomy, and treatment of CS with an emphasis on the proper performance of a two incision four compartment fasciotomy of the lower leg. Proper fasciotomy requires extensive knowledge of the anatomical landmarks and anatomy of the compartments of the extremities. Optimal outcomes result from early recognition of CS and aggressive, properly performed fasciotomy. As a result, otherwise well-trained surgeons are ill prepared to recognize and manage CS and to perform complete and adequate fasciotomies. The average number of fasciotomies reported in case logs submitted to the American Board of Surgery for 2013 graduates of US surgical residencies was 0.7, and the average number of fasciotomies reported by graduates of US vascular fellowships in the last decade has been between 0.8 and 2.0 per year. Bhattacharyya and Vrahas reported an average indemnity payment of $426,000 in nine cases settled between 19 in Massachusetts, and awards as high as $14.9 million have been made in cases of missed CS.
Disability resulting from CS is significant, and failure to diagnose or properly treat a CS is one of the most common causes of medical litigation, with significant malpractice liability.
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