ACS occurs when the pressure in a muscle compartment rises sufficiently to cause tissue ischemia leading to muscle or nerve damage. Impending ACS occurs when tissue pressure has begun to increase and tissue perfusion is reduced but is not sufficient to cause muscle or nerve damage. |
Risk factors |
Severe trauma: Long bone fracture, crush injury. |
Prolonged extremity ischemia with reperfusion. |
Spontaneous bleeding, hematoma. |
Burn injury, massive fluid resuscitation, SIRS. |
Others:* Myositis, myonecrosis, rhabdomyolysis, prolonged immobilization, bites and stings, high pressure injection, intravenous extravasation injury, soft tissue infection, intra-arterial injection, birth injury. |
Clinical features |
Physical examination alone has limited sensitivity and specificity for ACS. Serial examinations are important in patients at risk. Clinical features include: |
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Other clinical findings that suggest impending ACS include: |
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Initial measures and reassessment |
Normalize extremity perfusion (eg, fluid resuscitation, align fractures). |
Relieve external pressure on the compartment (eg, bivalve or remove cast, escharotomy for circumferential burns). |
Measure compartment pressures |
Whenever possible, pressure measurements should be obtained by the surgeon who will perform fasciotomy. |
Compartment pressures typically measured with handheld manometer. |
Needle (eg, 18 gauge) attached to a pressure transducer (eg, arterial line setup) can be used. |
Fasciotomy |
Extremity fasciotomy is the only recognized treatment. Early fasciotomy (ideally within four hours of symptom onset) can save the extremity. |
Indications:Δ
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Contraindications: Established late compartment syndrome is not likely to benefit from fasciotomy. Tissue damage becomes irreversible 4 to 8 hours after compartment pressure has increased. Fasciotomy for established ACS after 6 hours of onset increases the rate of infection and amputation. |
Techniques:
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Observation |
Patients in whom clinical suspicion is not high. |
Hourly reassessment for clinical features of ACS. |
Repeat compartment pressures, as needed. |
ACS: acute compartment syndrome; SIRS: systemic inflammatory response syndrome; CK: creatine kinase.
* Less common risk factors include nontraumatic muscle injury, severe deep vein thrombosis, soft tissue infection, extravasation injury, intra-arterial injection, and systemic inflammatory response syndrome.
¶ Reduced sensation, motor weakness, and diminished pulses are late findings.
Δ Prophylactic fasciotomy may be performed for patients at high risk for ACS but without symptoms.Do you want to add Medilib to your home screen?