Compartment syndrome is a painful condition which occurs from a muscle injury. When a muscle is injured, pressure in the tissues within a closed anatomic space increases. This limits blood flow to the area and potentially damages the muscles and surrounding nerves. Compartment syndrome can occur in the legs, feet, arms or hands; however, it can also develop in any enclosed compartment inside the body. The condition could be categorized as acute or chronic.
Tissue necrosis and permanent functional impairment are the expected consequences of compartment syndrome if treatment is not done on time. In severe cases, the condition may also result in renal failure or death.
Treatment of Acute Compartment Syndrome
The primary way to manage acute compartment syndrome is by the removal of any cast or dressing covering the limb. Close examination of the patient is the next step of treatment. It is recommended to keep the limb at heart level to perfuse the compartment. If the clinical condition does not improve after treatment, then the patient would need surgery.
Fasciotomy is a surgical method which helps to open the compartments and inhibit irreversible ischemic injury to muscles and peripheral nerves. Through fasciotomy, the following are attained:
- Adequate and extensile incision
- Complete release of all involved compartments
- Preservation of the affected muscled’s vital structure
- Detailed debridement
- Skin coverage after 7 to 10 days
Orthopedic, vascular, and plastic surgery are often required along with fasciotomy to deal with concomitant injuries. Post-operative pain is a primary characteristic of acute compartment syndrome. As such, adequate analgesia is recommended daily.
Treatment of Chronic Compartment Syndrome
Chronic Compartment Syndrome is suffered most commonly by runners and athletes. Due to constant physical activity, pain and pressure develops in one or more muscle compartments. Pain usually subsides by stopping the exercise. However, if the patient does not get relief from conservative measures, then surgery is the definitive treatment.
Runner's Compartment Syndrome - Mayo Clinic
Wound Management and Wound Complications of Compartment Syndrome
The management of fasciotomy wounds remains unclear. Most experts recommend leaving the wounds open with delayed primary closure or skin grafting within 7-10 days once the compartment syndrome has entirely resolved. It is also crucial to inspect the debridement after 48-72 hours. Simple absorbent dressings, semi-permeable membranes, and vessel loops in a ‘bootlace’ pattern or with negative pressure dressings are provided during interim coverage. These were found to be beneficial in allowing later wound closure.
Multiple Approaches for the Treatment of Compartment Syndrome
There are multiple approaches to decompress the compartments of the limbs. Depending on the affected compartments, incisions of the fasciotomy should be planned.
When compartment syndrome is diagnosed in the lower leg, it is recommended to decompress all of the leg compartments, including the retinacula. Either single lateral incision or combined anterolateral and posteromedial incisions are used for decompression. A single incision is prescribed in tibial fractures to sustain the stability of the fracture. Soft tissue support is reduced for the fracture in case of the double incision.
The following approaches are used in treating compartment syndromes in the foot area.
- Plantar Approach: A single plantar incision is recommended for a unique compartment syndrome of the calcaneal compartment which is compressed with medial and lateral plantar nerves and vessels. It is not a preferable approach.
- Dorsal Approach: This is the most frequently used approach. All the compartments could be directly accessed through this approach. It also offers exposure for open reduction and helps in internal fixation of Chopart or Lisfracture dislocations and tarsometatarsal fractures.
- Lateral Approach: At the lateral malleolus, the incision starts and is extended to the forefoot between the fourth and fifth metatarsals.
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