![]() ![]() The small, transverse fascial tears that usually result from open fractures do not adequately decompress the compartment. This significant finding dispels traditional teaching that open fractures naturally decompress and may not be as prone to compartment syndrome as closed fractures. Importantly, there is no difference between the ICPs of open and closed fractures meaning that all types of fractures need to be carefully monitored for signs of ACS. Tissue swelling and haematoma formation secondary to the fracture are possible mechanisms by which ICP is elevated after a fracture. Fractures of the tibial shaft occur most commonly, followed by distal radius and ulna fractures. Several series have demonstrated that fractures are the most common cause of ACS, accounting for as much as 69% of cases. There are several conditions that increase the volume of compartmental contents. In such patients, an escharotomy may be initially indicated. Patients with circumferential burns to the limbs are also at risk of ACS if they develop an inelastic eschar which prevents tissue expansion during swelling. Several papers have also reported the occurrence of ACS after operations, which require unnatural positioning of the patient such as some gynaecological conditions requiring the lithotomy position. It is therefore important for clinicians to be particularly alert in patients who have had periods of prolonged unconsciousness, such as drug users. In some cases, lying on a limb for prolonged periods has been implicated. Causes of a decrease in compartment size include tight dressings, bandages or casts. These two processes can occur either in isolation or concurrently. The causes of ACS either increase the volume of the contents of a compartment or reduce the capacity/volume of the compartment sheath (Box 1). This diagram was reused from Chandraprakasam and Kumar which allows fair reuse under the Creative Commons Licence. Schematic showing the 10 compartments of the hand: thenar (blue), hypothenar (light blue), adductor policis, and the four dorsal interossei (purple) and three volar interossei (cream). Muscles: brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevis Ĭontents of Upper and Lower Limb Compartments. Only three compartments traverse the entire length of the foot whilst five are confined only to the forefoot. Of note, there is no consensus regarding the number of foot compartments. There are 10 and 9 compartments in the hand (Fig. The feet and hands are complex structures, which may require specialist attention. Table 1 summarises the contents of the major limb compartments. Understanding the actions of the muscles in each muscle compartment may allow the localisation of affected compartment by clinical examination and may guide incision placement. through external compression, increase the intracompartmental pressure (ICP). Hence, conditions which either increase the volume of compartmental contents or decrease the capacity of the compartment e.g. This sheath limits the extent to which a compartment can accommodate an increase in the volume of its contents. Within the limbs, muscles are organised into tightly packed compartments, each containing muscle, arteries, nerves and lymphatic vessels and surrounded by an inelastic connective tissue sheath. ![]() These early ideas have since been refined by increased anatomical knowledge and diagnostic techniques. It has been thought for over a century that an increase in pressure was a central mechanism in the evolution of ACS through the early work of von Volkmann. ![]() However, in this clinical review only the relevant clinical anatomy, aetiology, pathophysiology, risk factors, clinical features, diagnostic procedures and management of an acute presentation of limb compartment syndrome are discussed. It is also important to note that presentations of compartment syndrome are not always acute, but may be sub-acute and at times chronic. Ĭompartment syndromes can arise in any area of the body that has little or no capacity for tissue expansion, such as the abdomen, buttocks and hands. A study of 23 years of records on closed malpractice claims found that the average indemnity payment in the United States was $426 000 in addition to a mean cost of $29 500 to defend each case. Adverse patient outcomes due to delayed or missed diagnosis also have significant medico-legal ramifications for surgeons. Schwartz et al., reported a mortality rate of 47% in patients with ACS of the thigh. Unrecognised ACS can leave patient with nonviable limbs requiring amputation and can also be life–threatening. A failure or delay in recognising ACS almost invariably results in adverse outcomes for patients. Acute compartment syndrome (ACS) of the limb refers to a constellation of symptoms, which occur following a rise in the pressure inside a limb muscle compartment. ![]()
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