Compartment syndrome

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Compartment syndrome is an acute medical problem following injury, surgery or in most cases repetitive and extensive muscle use, in which increased pressure (usually caused by inflammation) within a confined space (fascial compartment) in the body impairs blood supply. Without prompt treatment, it may lead to nerve damage and muscle death. This condition is most commonly seen in the anterior compartment and posterior compartment of the leg.

Because the connective tissue that defines the compartment does not stretch, a small amount of bleeding into the compartment, or swelling of the muscles within the compartment can cause the pressure to rise greatly. Common causes of compartment syndrome include tibial or forearm fractures, ischemic-reperfusion following injury, hemorrhage, vascular puncture, intravenous drug injection, casts, prolonged limb compression, crush injuries and burns.[1][2] Another possible cause can be from the use of creatine monohydrate. Past use of creatine has been known to cause this condition.[3][4]

When compartment syndrome is caused by repetitive heavy use of the muscles, as in a cyclist, it is known as chronic compartment syndrome (CCS).[5][6] This is usually not an emergency, but the loss of circulation can cause temporary or permanent damage to nearby nerves and muscle.

Any condition that results in an increase in compartment contents or reduction in a compartment’s volume could lead to the development of an acute compartment syndrome. When pressure is elevated capillary blood flow is compromised. Edema of the soft tissue within the compartment further raises the intra-compartment pressure, which compromised venous and lymphatic drainage of the injured area. Pressure, if further increased in a reinforcing vicious cycle, can compromise arteriole perfusion, leading to further tissue ischemia.

The normal mean interstitial tissue pressure is near zero mmHg in non-contracting muscle. If this pressure becomes elevated to 30 mmHg or more, small vessels in the tissue become compressed, which leads to reduced nutrient blood flow i.e., ischemia and pain. Of particular importance is the difference between compartment pressure and diastolic blood pressure; where diastolic blood pressure exceeds compartment pressure by less than 30mmHg it is considered an emergency.

Untreated compartment syndrome mediated ischemia of the muscles and nerves lead to eventual irreversible damage and death of the tissues within the compartment.

There are classically 5 “Ps” associated with compartment syndrome — pain out of proportion to what is expected, paraesthesia, pallor, paralysis, pulselessness; sometimes a 6th P, for polar/poikilothermia (i.e. cold) is added. Of these only the first two are reliable in the latter stages of compartment syndrome. [7][8]

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