Complications of Fracture – Compartment Syndrome

Incision for fasciotomy done for compartment syndrome

Incision for fasciotomy done for compartment syndrome

Compartment syndrome is a condition caused by increased pressure within a confined space, or compartment, in the body. It mostly is associated with fracture of tibia, forearm fractures, foot injuries and hand injuries.

Compartment syndrome results in ischaemia of the tissues. If untreated, it can result in necrosis  of the muscles and other tissues.

However, rapid diagnosis and treatment can lead to complete recovery.

How Does It Occur?

When fracture occurs, the force of injury also results in soft tissue injury. Bleeding from the bone or other tissues accumulate in muscle compartments which are limited by fasciae and muscular septae.  This causes elevation of the pressure in the compartment andcapillary blood flow is compromised.

Ischaemia or decreased tissue perfusion results in edema of the soft tissue which  further raises the intra-compartment pressure. Venous and and lymphatic drainage of the injured area gets compromised, adding further insult. This furter increases the pressure and  vicious cycle is formed.

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

Clinical Presentation

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.

  • Pain is is usually of severe, deep, constant, and poorly localized and is sometimes described as out of proportion with the injury. The pain is aggravated by stretching the muscle group within the compartment and is not relieved by analgesia.
  • Paresthesia (alterated sensation e.g. “pins & needles”) in the cutaneous nerves of the affected compartment is another typical sign.
  • Paralysis of the limb is usually a late finding. The compartment may feel very tense and firm as well (pressure).
  • Lack of pulse rarely occurs in patients. and is not a reliable sign. Moreover, it is present in very late stages. Pulse is only affected if the relevant artery is contained within the affected compartment.

Compartmental Pressure
Gauging the pressure within the muscle compartments would guide about compartment syndrome.

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.

When diastolic blood pressure exceeds compartment pressure by less than 30mmHg it is considered an emergency.

Treatment

Acute compartment syndrome is a medical emergency. It requires opening up of compartments to release pressure. This procedure is called fasciotomy.

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Comments

  1. says

    I got shot roughly 4 years ago by a high velocity bullet in the left lower leg. I lost bout 1/2 my calf and half of my achilles tendon. Since that time my calf muscle(whats left of it) has been steadily swelling up and been getting more painful. It is now bigger than my normal right leg. When i am at work and where full length work boots I can walk normally without to much pain, but when wearing normal shoes I have alot of pain (dull ache and pins and needles since so much nerve damage) and walk with a limp. I find it hard to sleep at night, the pain wakes me up every couple hours. Are these problems after loosing so much of your calf muscle and achilles tendon. I took pain killers for along time but can't stand them.

  2. Dr Arun Pal Singh says

    @james peavyhouse,

    I would advise you to see a doctor who can evaluate you and make a diagnosis.

  3. Karen says

    I had surgery for Compartment Syndrome in June. I stll have stabbing pains in my foot 7 months later. I also have a numb feeling on the top of my foot and lower leg. Just wondering if this is normal and will I have this for the rest of my life. Also still to this day my Dr. has no idea what caused this. I had gone to emerg 4 times within 4 days before i was diagnosed and rushed to surgery. I'm very grateful to still have my leg but very frustrated with the pain. I'm seeing a vascular surgeon the end of Jan and hopefully will gain some insight as to what is happing with my leg. My incision is identical to the one on this page only alittle lower on my leg.

    Thank you

    Karen

  4. Dr Arun Pal Singh says

    @Karen,

    Looks like a nerve damage/compression. I think investigations for nerve conduction can guide youon that.

    A nerve root involvement in the spine should also be ruled out.

  5. humayun sami says

    i have ankle twist in the right foot which leads to swelling in the foot.after a week all my reports went wrong like renal reports,lft and all blood reports.

    i got admitted doctors give me high potensy steroids to control the infection.foot swelling was never improved.

    gradually reports get ok but swelling remains.there were signs of gangrein as well on my leg.doctors treated several time made cuts on legs removed dead tissue but swelling on foot remains but there was no feeling and moment in foot.

    i was continuously on anti biotics.

    now after 4 months doctor say bones are getting infected with strong smell(although they removed some infected bones as well.

    doctor now say they have to cut the foot.i am too much worried over it.

    plz reply at ur earliest

  6. Dr Arun Pal Singh says

    @humayun sami,

    Getting a foot amputated is a real serious issue. You should get opinion from a doctor whom you can see physically and who can examine you.

    If you have doubts, get a second opinion.

    I am sorry I would not be able to help you.

  7. Jane says

    I was kicked hard in the shin (tibia) 6 mths ago. It swelled at the front, then brusing came out and also around the ankle where it had 'drained' for want of a better description.

    Now I have tightness of calf and the under of foot (also on right leg) feels unusual, having a few muscle spasms and the muscle close to shin feels tight, could this be compartment syndrome eventhough injury was 6mths ago?

    Could I also have had a small fracture also without realising?

  8. Dr Arun Pal Singh says

    @Jane,

    Did you see a doctor. There is little chance of getting a compartment syndrome from anterior tibial trauma.

    Even if there was a small fracture, it would not matter.