A slice in time: Lower extremity compartment syndrome

The definition of compartment syndrome has evolved over the last two centuries. Volkmann first introduced the concept of compartment syndrome when he described post-traumatic ischemic muscle injury leading to paralytic limb contractures, which he termed Volkmann’s Contracture in 1881.* The more modern definition from Carter et al describes muscle swelling within a fixed muscular compartment impairing distal blood supply leading to necrosis. Physicians now agree that compartment syndrome occurs when pressure within a closed space increases past a critical pressure (typically greater than 30 mmHg), resulting in decreased perfusion to the components of the compartment and the sequelae following such an insult (muscle edema, ischemia, and necrosis).

Prompt diagnosis and treatment

Lower extremity gunshot wounds, stab wounds, fractures as a result of blunt injuries, and prolonged pressure on an extremity are common causes of lower extremity compartment syndrome in trauma patients. No matter the mechanism of injury, prompt diagnosis and treatment of compartment syndrome is essential.

The classic signs of acute compartment syndrome include the six “Ps”: pain, paresthesia, poikilothermia (differing temperatures between limbs with affected side being cooler), pallor, paralysis, and pulselessness. Pain that is disproportionate to injury must trigger a workup for compartment syndrome. Pain is often described as a dull, deep, aching worsened by passive stretching of the involved muscles in the lower extremity or dorsiflexion of the foot. Paresthesias in the web space between the first and second toes is also an early indicator of compartment syndrome. Paralysis and pulselessness is often a late indicator of compartment syndrome and many times results after irreversible nerve and muscle injury have already occurred.

Suspicion of compartment syndrome should prompt further workup or definitive treatment. Compartment pressures may have a limited role in diagnosis but are useful in patients without a reliable physical examination. Several commercially available devices allow for pressures to be measured within the muscular compartments of concern. An absolute compartment pressure greater than 30 mmHg is concerning for compartment syndrome. Calculating the “delta-p” (diastolic blood pressure minus intracompartment pressure) is an additional way to determine the need for operative intervention. Whitesides in 1975 suggested that a compartment was at risk when the compartment pressure was within 10–30 mmHg of the diastolic blood pressure. The definitive treatment of compartment syndrome is fasciotomy.

To examine the occurrence of lower extremity compartment syndrome in the National Trauma Data Bank® (NTDB®) research admission year 2016, medical records were searched using the International Classification of Diseases, 10th Revision Clinical Modification codes. Specifically searched were records that contained a diagnosis code of either T79.A21 (traumatic compartment syndrome of right lower extremity) or T79.A22 (traumatic compartment syndrome of left lower extremity). A total of 979 records were found, of which 937 contained a discharge status, including 656 patients discharged to home, 160 to acute care/rehab, and 87 to skilled nursing facilities; 34 died (see Figure 1). Of these patients, 82 percent were men, on average 38.1 years of age, had an average hospital length of stay of 12.8 days, an intensive care unit length of stay of 7.7 days, an average injury severity score of 9.4, and were on the ventilator for an average of 7.2 days. Of those tested, 26 percent (105 out of 403) were over the legal limit for alcohol.

Figure 1. Hospital discharge status

Figure 1. Hospital discharge status

Several different mechanisms of injury may result in a lower extremity compartment syndrome. No matter the etiology, if the diagnosis and treatment are delayed, serious sequelae will occur. Examples include muscle loss, permanent nerve injury, functional loss, or even amputation. However, urgent operative fasciotomy provides a slice in time that will go a long way to reduce the potential morbidity of lower extremity compartment syndrome.

Throughout the year, we will be highlighting these data through brief reports in the Bulletin. The NTDB Annual Report can be found on the on the ACS website as a PDF file. In addition, information is available on the website about how to obtain NTDB data for more detailed study. To submit your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at mneal@facs.org.

Acknowledgment

Statistical support for this article was provided by Ryan Murphy, Data Analyst, NTDB.


*Griffiths DV. Volkmann’s ischaemic contracture. Br J Surg .1940;28:239-260.

Carter AB, Richards RL, Zachary RB. The anterior tibial syndrome. Lancet. 1949;2(6586):928-934.

Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res. 1975;113:43-51.

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