Синдром компартмента: причины, симптомы и осложнения.

Condition in which increased pressure results in insufficient blood supply

Compartment syndrome usually presents within a few hours of an inciting event, but may present anytime up to 48 hours after. Usually, the pain cannot be relieved by NSAIDs.

There are five characteristic signs and symptoms related to acute compartment syndrome: pain, paresthesia (reduced sensation), paralysis, pallor, and pulselessness. This pain can occur for months, and in some cases over a period of years, and may be relieved by rest. Foot drop is a common symptom of CECS.

Failure to relieve the pressure can result in the death of tissues (necrosis) in the affected anatomical compartment, since the ability of blood to enter the smallest vessels in the compartment (capillary perfusion pressure) will fall. This, in turn, leads to progressively increasing oxygen deprivation of the tissues dependent on this blood supply. Without sufficient oxygen, the tissue will die. On a large scale, this can cause Volkmann's contracture in affected limbs, a permanent and irreversible process. Other reported complications include neurological deficits of the affected limb, gangrene, and chronic regional pain syndrome. Rhabdomyolysis and subsequent kidney failure are also possible complications. In some case series, rhabdomyolysis is reported in 23% of patients with ACS. The lower legs and the forearms are the most frequent sites affected by compartment syndrome. Other areas of the body such as thigh, buttock, hand, abdomen, and foot can also be affected. There is no difference between acute compartment syndrome originating from an open or closed fracture. Leg compartment syndrome is found in 2% to 9% of tibial fractures. It is strongly related to fractures involving the tibial diaphysis as well as other sections of the tibia. Direct injury to blood vessels can lead to compartment syndrome by reducing the downstream blood supply to soft tissues. This reduction in blood supply can cause a series of inflammatory reactions that promote the swelling of the soft tissues. Such inflammation can be further worsened by reperfusion therapy. Patients on anticoagulant therapy have an increased risk of bleeding into a closed compartment. Compartment syndrome after snake bite is rare. Its incidence varies from 0.2 to 1.36% as recorded in case reports. Compartment syndrome is more common in children possibly due to inadequate volume of the bodily fluid to dilute the snake venom.

When compartment syndrome is caused by repetitive use of the muscles, it is known as chronic compartment syndrome (CCS). This is usually not an emergency, but the loss of circulation can cause temporary or permanent damage to nearby nerves and muscles. A subset of chronic compartment syndrome is chronic exertional compartment syndrome (CECS), often called exercise induced compartment syndrome (EICS). Oftentimes, CECS is a diagnosis of exclusion. CECS of the leg is a condition caused by exercise which results in increased tissue pressure within an anatomical compartment due to an acute increase in muscle volume – as much as 20% is possible during exercise. When this happens, pressure builds up in the tissues and muscles causing tissue ischemia. This worsening cycle can eventually lead to a lack of sufficient oxygen in the soft tissues (tissue ischemia) and tissue death (necrosis). Tingling and abnormal sensation (paresthesia) can begin as early as 30 minutes from the start of tissue ischemia and permanent damage can occur as early as 12 hours from the onset of the inciting injury. Fasciotomy is indicated in that case. For those patients with low blood pressure (hypotension), a pressure of 20 mmHg higher than the intracompartmental pressure is associated with compartmental syndrome. Chronic exertional compartment syndrome is usually a diagnosis of exclusion, with the hallmark finding being absence of symptoms at rest. Measurement of intracompartmental pressures during symptom reproduction (usually immediately following running) is the most useful test. Imaging studies (X ray, CT, MRI) can be useful in ruling out other more common diagnoses instead of confirming the diagnosis of compartment syndrome. Additionally, MRI has been shown to be effective in diagnosing chronic exertional compartment syndrome. The average duration of symptoms prior to diagnosis is 28 months.

Any external compression (tourniquet, orthopedic casts or dressings applied on the affected limb) should be removed. Cutting of the cast will reduce the intracompartmental pressure by 65%, followed by 10 to 20% pressure reduction once padding is cut. After removal of the external compression the limb should be placed at the level of the heart. The vital signs of the patient should be closely monitored. If the clinical condition does not improve, then fasciotomy is indicated to decompress the compartments. An incision large enough to decompress all the compartments is necessary. This surgical procedure is performed inside an operating theater under general or local anesthesia. A skin graft may be required to close the wound, which would complicate the treatment with a much longer hospitalization stay. Compartment syndrome due to snake bite should be treated with antivenom, and, unlike more common causes, fasciotomy is rarely indicated. If the pressure does not reduce after administration of antivenom, the treatment is to administer more antivenom. Compartment pressure should be measured before and after administration of antivenom, and only those patients who fail to respond to additional antivenom should receive a fasciotomy.

Treatment for chronic exertional compartment syndrome can include decreasing or subsiding exercise and/or exacerbating activities, massage, non steroidal anti inflammatory medication, and physiotherapy. Chronic compartment syndrome in the lower leg can be treated conservatively or surgically. Conservative treatment includes rest, anti inflammatory medications, and manual decompression. Warming the affected area with a heating pad may help to loosen the fascia prior to exercise. Icing the area may result in further constriction of the fascia and is not recommended before or after exercise. The use of devices that apply external pressure to the area, such as splints, casts, and tight wound dressings, should be avoided. If symptoms persist after conservative treatment or if an individual does not wish to give up the physical activities which bring on symptoms, compartment syndrome can be treated by a surgery known as a fasciotomy. A US military study conducted in 2012 found that teaching individuals with lower leg chronic exertional compartment syndrome to change their running style to a forefoot running technique abated symptoms in those with symptoms limited to the anterior compartment. Running with a forefoot strike limits use of the tibialis anterior muscle which may explain the relief in symptoms in those with anterior compartment syndrome. Hyperbaric oxygen therapy has been suggested by case reports – though as of 2011 not proven in randomized control trials – to be an effective adjunctive therapy for crush injury, compartment syndrome, and other acute traumatic ischemias, by improving wound healing and reducing the need for repetitive surgery.

A mortality rate of 47% has been reported for acute compartment syndrome of the thigh. According to one study the rate of fasciotomy for acute compartment syndrome varied from 2% to 24%.

In one case series of 164 people with acute compartment syndrome, 69% of the cases had an associated fracture. The authors of that article also calculated an annual incidence of acute compartment syndrome of 1 to 7.3 per 100,000. There are significant differences in the incidence of acute compartment syndrome based on age and gender in the setting of trauma. Acute compartment syndrome may occur more often in individuals less than 35 years old due to increased muscle mass within the compartments .