QuestionSBA
QuestionChoice
This is an early finding in compartment syndrome
32136
d
Burning pain in the affected limb
QuestionChoice
The patient has developed compartment syndrome due to significant trauma causing bleeding and raised intracompartmental pressure within the limb. Late findings may also include the absence of distal pulses, and hypoesthesia. The patient would require an urgent fasciotomy to relieve the pressure within the compartment. It is important to remember always to have a high index of suspicion for compartment syndrome as clinical signs may be varied, and consider urgent referral for any patient with a tense, painful muscle compartment
32133
a
Paralysis of the affected limb
QuestionChoice
This is an early and common finding in compartment syndrome
32137
e
Severe pain in the limb out of proportion to clinical findings
QuestionChoice
This is an early finding in compartment syndrome
32134
b
Pain on passive muscle stretch
QuestionChoice
Tingling sensations in the limb are an early finding in compartment syndrome and would suggest ischaemic nerve dysfunction. Sensory deficits would typically precede motor deficits, i.e. weakness of the limb
32135
c
Paraesthesia of the affected limb
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Dominant Tachycardia
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# Summary
 
Compartment syndrome occurs when an increase in pressure in a closed anatomical compartment causes local tissue ischaemia. Typically the increase in pressure is secondary to inflammation caused by a traumatic injury, usually a fracture. Key signs and symptoms include severe pain out of keeping with the associated injury, particularly during passive stretching, pallor, limb paralysis, pulselessness, and paraesthesia. Rapid diagnosis is crucial to prevent complications of limb loss, loss of function and rhabdomyolysis causing renal failure. Diagnosis is clinical however compartment pressures may be measured at the bedside or during surgery. Definitive management is urgent fasciotomy, with IV fluids and analgesia both important. 

# Definition
 
Compartment syndrome refers to the condition that results when inflammation of injured muscle causes an increase in pressure within a fascial compartment. As the pressure rises, circulation is cut off leading to tissue ischaemia and necrosis. 
 
# Aetiology

The majority of cases of compartment syndrome occur secondary to fractures, with tibial, forearm and wrist fractures carrying the highest risk. 

Other causes include:

- Crush injuries
- Excessive exercise
- Constrictive dressings or plaster casts
- Prolonged immobilisation
- Reperfusion of ischaemic limbs

# Signs and Symptoms

The classic symptom of compartment syndrome is severe pain that is typically out of proportion to the initial injury. On examination, passive stretching of the affected muscles exacerbates the pain.

Other signs and symptoms occur sequentially as the increasing pressure initially compresses veins, followed by nerves then arteries:

- Paraesthesia
- Pallor 
- Pulselessness
- Paralysis
- Coolness of the affected limb
- The area may feel tense on palpation


# Differential Diagnosis
 
- **Deep vein thrombosis** also causes pain and may be associated with immobility and inflammation after injury, however the affected area is usually warm, erythematous and swollen
- **Cellulitis** also causes localised pain and may be associated with injury; the patient may also be systemically unwell, however skin is erythematous and warm to touch 
- **Acute limb ischaemia** can both result from compartment syndrome and may also lead to compartment syndrome after reperfusion, however they are not always associated and are managed differently. Symptoms and signs of pain, paraesthesia, pallor, pulselessness, paralysis and "perishing" coldness of the limb are classic but the significant pain of compartment syndrome and a preceding injury may not be seen.

# Investigations

Compartment syndrome is a clinical diagnosis, however it is possible to measure intra-compartmental pressures directly (for example in atypical presentations). Normal compartment pressures are 0-8mmHg; in compartment syndrome these are often above 40mmHg. A difference between the patient's diastolic blood pressure and the compartment pressure of under 30mmHg is suggestive of compartment syndrome.

Other useful tests include:

- **CK** is often elevated due to ischaemic muscle damage
- **U&Es** may be deranged secondary to rhabdomyolysis
- **FBC**, **LFTs**, **clotting** and **group and saves** should be done in preparation for surgery
- An **ECG** should also be done in preparation for surgery; arrhythmias may occur secondary to rhabdomyolysis

# Management

- Urgent surgical referral for immediate fasciotomies is the key management - surgery should occur within an hour of deciding to operate
- This involves making surgical incisions through the fascia to relieve the pressure in the affected compartment
- These incisions are left open and further operations may be required to debride necrotic tissues - a re-exploration should be performed at 24-48 hours
- Remove any circumferential dressings or casts
- Elevate the limb to the level of the heart to maximise perfusion
- Resuscitate with IV fluids and supplementary oxygen to maintain perfusion and oxygenation
- Ensure adequate analgesia is given (usually IV opioids); avoid regional anaesthesia as this may mask symptoms
- Close monitoring including the neurovascular status of the limb is crucial
- Ensure other injuries are addressed; intensive care input may be required especially if serious complications arise (e.g. renal failure secondary to rhabdomyolysis)

# Complications
 
- **Rhabdomyolysis** due to ischaemia of muscles, which may lead to renal failure and arrhythmias as well as death
- **Limb amputation** may be required if there is extensive necrosis of tissues
- **Volkmann contracture** refers to an ischaemic contracture which causes a flexion deformity of a limb due to ischaemic injury of its deep tissues

# References

[British Orthopaedic Assocation - Diagnosis and Management of Compartment Syndrome of the Limbs](https://www.boa.ac.uk/static/0d37694f-1cad-40d5-b4c1032eef7486ff/de4cfbe1-6ef3-443d-a7f2a0ee491d2229/diagnosis%20and%20management%20of%20compartment%20syndrome%20of%20the%20limbs.pdf) 

[Life in the Fast Lane - Compartment Syndrome](https://litfl.com/compartment-syndrome-ccc/)

[Radiopaedia - Acute Compartment Syndrome](https://radiopaedia.org/articles/acute-compartment-syndrome?lang=gb)

[Patient UK - Compartment Syndrome](https://patient.info/doctor/compartment-syndrome-pro)
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2097
Compartment syndrome
Topic
37
Orthopaedics
6427
Compartment syndrome can lead to paralysis of the affected limb if not promptly diagnosed and treated.
A 40-year-old motorcyclist is involved in a road collision accident and sustains a displaced tibial shaft fracture. He undergoes closed reduction, and his leg is immobilised in a long cast. A few hours after the procedure, he complains of severe pain in the affected limb that seems disproportionate to clinical findings.

Given the most likely complication that has occurred, which of the following is considered a late finding in his condition?
a