Leg Compartment Syndrome Unveiled: Understanding the Devastating Effects
Gain insight into leg compartment syndrome, a condition that can cause irreversible damage. Learn about the symptoms, diagnosis, and treatment options for this lower extremity condition.
The leg is divided into four osseofascial compartments:
- Anterior compartment
- Lateral compartment
- Superficial posterior compartment
- Deep posterior compartment
These compartments are divided by various structures such as the interosseous membrane of the leg, transverse intermuscular septum, and anterior intermuscular (crural) septum.
Compartment Contents
The contents of each compartment are as follows:
- Anterior compartment:
- Muscular: tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius
- Neurovascular: deep peroneal nerve, anterior tibial vessels
- Lateral compartment:
- Muscular: peroneus longus, peroneus brevis
- Neurovascular: superficial peroneal nerve
- Superficial posterior compartment:
- Muscular: gastrocnemius, plantaris, soleus
- Neurovascular: sural nerve
- Deep posterior compartment:
- Muscular: tibialis posterior, flexor hallucis longus, flexor digitorum longus, popliteus
- Neurovascular: tibial nerve, posterior tibial vessels
SUMMARY
Leg Compartment Syndrome is a devastating lower extremity condition where the osseofascial compartment pressure rises to a level that decreases perfusion to the leg and may lead to irreversible muscle and neurovascular damage.
Diagnosis is made with the presence of severe and progressive leg pain that worsens with passive ankle motion. Firmness and decreased compressibility of the compartments is often present. Needle compartment pressures are diagnostic in cases of inconclusive physical exam findings and in sedated patients.
Treatment is usually emergent fasciotomies of all 4 compartments.
EPIDEMIOLOGY
Anatomic location:
Compartment syndrome may occur anywhere that skeletal muscle is surrounded by fascia, but most commonly in the leg (details below), forearm, hand, foot, thigh, buttock, shoulder, and paraspinous muscles.
ETIOLOGY:
Pathophysiology:
Etiology includes trauma (fractures, crush injuries, contusions, gunshot wounds, tight casts, dressings, or external wrappings, extravasation of IV infusion, burns, postischemic swelling), bleeding disorders, and arterial injury.
Pathoanatomy includes local trauma and soft tissue destruction, bleeding and edema, increased interstitial pressure, vascular occlusion (decreased venous outflow relative to arterial inflow), and myoneural ischemia.
Risk factors include diaphyseal fractures and young age (highest prevalence in 12-19 year olds).
ANATOMY
4 compartments of the leg:
- Anterior compartment:
- Lateral compartment:
- Deep posterior compartment:
- Superficial posterior compartment:
Function: dorsiflexion of foot and ankle
Muscles: tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius
Function: plantarflexion and eversion of foot
Muscles: peroneus longus, peroneus brevis (isolated lateral compartment syndrome would only affect superficial peroneal nerve)
Function: plantarflexion and inversion of foot
Muscles: tibialis posterior, flexor digitorum longus, flexor hallucis longus
Function: mainly plantarflexion of foot and ankle
Muscles: gastrocnemius, soleus, plantaris
PRESENTATION
Symptoms:
- Pain out of proportion to the clinical situation is usually the first symptom.
- Pain may be absent in cases of nerve damage.
Physical exam:
- Pain with passive stretch is the most sensitive finding prior to the onset of ischemia.
- Paresthesia and hypoesthesia are indicative of nerve ischemia in the affected compartment.
- Paralysis is a late finding, and full recovery is rare in this case.
- Palpable swelling, peripheral pulses absent, and amputation are usually inevitable in late-stage cases.
IMAGING
Radiographs should be obtained to rule out fractures.
STUDIES
Compartment pressure measurements:
- Indications include polytrauma patients, patients who are not alert or unreliable, and inconclusive physical exam findings.
- Relatively contraindicated in cases with unequivocally positive clinical findings, which should prompt emergent operative intervention without the need for compartment measurements.
Technique:
- Measurements should be performed within 5cm of the fracture site.
- Low rates of interobserver reliability have been noted with measurements.
- Anterior compartment measurement:
- Entry point: 1cm lateral to anterior border of tibia within 5cm of fracture site if possible.
- Needle should be perpendicular to the skin.
- Deep posterior compartment measurement:
- Entry point: just posterior to the medial border of tibia.
- Advance needle perpendicular to the skin towards the fibula.
- Lateral compartment measurement:
- Entry point: just anterior to the posterior border of fibula.
- Superficial posterior compartment measurement:
- Entry point: middle of calf within 5cm of fracture site if possible.
DIAGNOSIS
Clinical diagnosis is based primarily on physical exam in a patient with intact mental status.
TREATMENT
Nonoperative:
- Observation is indicated when the diastolic differential pressure (delta p) is > 30 and the presentation is not consistent with compartment syndrome.
- Bi-valving the cast and loosening circumferential dressings are additional nonoperative treatment options.
- Splinting the ankle between neutral and resting plantar flexion can also decrease intracompartmental pressures.
- Hyperbaric oxygen therapy can be considered as it works by increasing the oxygen diffusion gradient.
Operative:
- Emergent fasciotomy of all four compartments is the standard treatment.
- Indications for operative intervention include a clinical presentation consistent with compartment syndrome and compartment pressures within 30 mm Hg of diastolic blood pressure (delta p).
- During surgery, comparison to pre-operative diastolic pressure is necessary, and attempts should be made to restore systemic blood pressure prior to measurement.
- Contraindications include missed compartment syndrome.
Special considerations:
- In pediatric cases, compartment pressure measurement should be performed under sedation as children are unable to verbalize their feelings.
- In hemophiliacs, Factor VIII replacement should be given before measuring compartment pressures.
TECHNIQUES
Emergent fasciotomy of all four compartments can be performed using dual medial-lateral incisions or a single lateral incision.
Dual medial-lateral incision approach:
- Make two 15-18cm vertical incisions separated by 8cm skin bridge.
- Anterolateral incision:
- Identify and protect the superficial peroneal nerve.
- Perform fasciotomy of anterior compartment 1cm in front of intermuscular septum.
- Perform fasciotomy of lateral compartment 1cm behind intermuscular septum.
- Posteromedial incision:
- Protect saphenous vein and nerve.
- Incise superficial posterior compartment.
- Detach soleal bridge from back of tibia to adequately decompress deep posterior compartment.
- Post-operative: Dressing changes followed by delayed primary closure or skin grafting at 3-7 days post decompression.
Single lateral incision approach:
- Make a single lateral incision from the head of the fibula to the ankle along the line of the fibula.
- Identify superficial peroneal nerve.
- Perform anterior compartment fasciotomy 1cm anterior to the intermuscular septum.
- Perform lateral compartment fasciotomy 1cm posterior to the intermuscular septum.
- Identify and perform fasciotomy on superficial posterior compartment.
- Reach the deep posterior compartment by following the interosseous membrane from the posterior aspect of the fibula and releasing the compartment from this membrane.
- Common peroneal nerve is at risk with proximal disse
SUMMARY
Leg Compartment Syndrome is a devastating lower extremity condition where the compartment pressure rises to a level that decreases perfusion to the leg and may lead to irreversible muscle and neurovascular damage.
Diagnosis is made with the presence of severe and progressive leg pain that worsens with passive ankle motion. Firmness and decreased compressibility of the compartments is often present. Needle compartment pressures are diagnostic in cases of inconclusive physical exam findings and in sedated patients.
Treatment is usually emergent fasciotomies of all 4 compartments.
EPIDEMIOLOGY
Anatomic location:
Compartment syndrome may occur anywhere that skeletal muscle is surrounded by fascia, but most commonly in the leg (details below), forearm, hand, foot, thigh, buttock, shoulder, and paraspinous muscles.
ETIOLOGY:
Pathophysiology:
Etiology includes trauma (fractures, crush injuries, contusions, gunshot wounds, tight casts, dressings, or external wrappings, extravasation of IV infusion, burns, postischemic swelling), bleeding disorders, and arterial injury.
Pathoanatomy includes local trauma and soft tissue destruction, bleeding and edema, increased interstitial pressure, vascular occlusion (decreased venous outflow relative to arterial inflow), and myoneural ischemia.
Risk factors include diaphyseal fractures and young age (highest prevalence in 12-19 year olds).
ANATOMY
4 compartments of the leg:
Function: function1
Muscles: muscle1, muscle2, muscle3, muscle4
Function: function2
Muscles: muscle5, muscle6
Function: function3
Muscles: muscle7, muscle8, muscle9
Function: function4
Muscles: muscle10, muscle11, muscle12, muscle13
- Compartment 1:
- Compartment 2:
- Compartment 3:
- Compartment 4:
PRESENTATION
Symptoms:
- Pain out of proportion to the clinical situation is usually the first symptom.
- Pain may be absent in cases of nerve damage.
Physical exam:
- Pain with passive stretch is the most sensitive finding prior to the onset of ischemia.
- Paresthesia and hypoesthesia are indicative of nerve ischemia in the affected compartment.
- Paralysis is a late finding, and full recovery is rare in this case.
- Palpable swelling, peripheral pulses absent, and amputation are usually inevitable in late-stage cases.
IMAGING
Radiographs should be obtained to rule out fractures.
STUDIES
Compartment pressure measurements:
- Indications include polytrauma patients, patients who are not alert or unreliable, and inconclusive physical exam findings.
- Relatively contraindicated in cases with unequivocally positive clinical findings, which should prompt emergent operative intervention without the need for compartment measurements.
Technique:
- Measurements should be performed within 5cm of the fracture site.
- Low rates of interobserver reliability have been noted with measurements.
- Compartment 1 measurement:
- Entry point: 1cm lateral to anterior border of tibia within 5cm of fracture site if possible.
- Needle should be perpendicular to the skin.
- Compartment 4 measurement:
- Entry point: just posterior to the medial border of tibia.
- Advance needle perpendicular to the skin towards the fibula.
- Compartment 2 measurement:
- Entry point: just anterior to the posterior border of fibula.
- Compartment 3 measurement:
- Entry point: middle of calf within 5cm of fracture site if possible.
DIAGNOSIS
Clinical diagnosis is based primarily on physical exam in a patient with intact mental status.
TREATMENT
Nonoperative:
- Observation is indicated when the diastolic differential pressure (delta p) is > 30 and the presentation is not consistent with compartment syndrome.
- Bi-valving the cast and loosening circumferential dressings are additional nonoperative treatment options.
- Splinting the ankle between neutral and resting plantar flexion can also decrease intracompartmental pressures.
- Hyperbaric oxygen therapy can be considered as it works by increasing the oxygen diffusion gradient.
Operative:
- Emergent fasciotomy of all four compartments is the standard treatment.
- Indications for operative intervention include a clinical presentation consistent with compartment syndrome and compartment pressures within 30 mm Hg of diastolic blood pressure (delta p).
- During surgery, comparison to pre-operative diastolic pressure is necessary, and attempts should be made to restore systemic blood pressure prior to measurement.
- Contraindications include missed compartment syndrome.
Special considerations:
- In pediatric cases, compartment pressure measurement should be performed under sedation as children are unable to verbalize their feelings.
- In hemophiliacs, Factor VIII replacement should be given before measuring compartment pressures.
TECHNIQUES
Emergent fasciotomy of all four compartments can be performed using dual medial-lateral incisions or a single lateral incision.
Dual medial-lateral incision approach:
- Make two 15-18cm vertical incisions separated by 8cm skin bridge.
- Anterolateral incision:
- Identify and protect the superficial peroneal nerve.
- Perform fasciotomy of compartment 1 1cm in front of intermuscular septum.
- Perform fasciotomy of compartment 2 1cm behind intermuscular septum.
- Posteromedial incision:
- Protect saphenous vein and nerve.
- Incise compartment 3.
- Detach soleal bridge from back of tibia to adequately decompress compartment 4.
- Post-operative: Dressing changes followed by delayed primary closure or skin grafting at 3-7 days post decompression.
Single lateral incision approach:
- Make a single lateral incision from the head of the fibula to the ankle along the line of the fibula.
- Identify superficial peroneal nerve.
- Perform compartment 1 fasciotomy 1cm anterior to the intermuscular septum.
- Perform compartment 2 fasciotomy 1cm posterior to the intermuscular septum.
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"The Leg's Four Compartments: Muscles, Nerves, and Vessels Explained" Discover the four compartments of the leg, their contents, and how they are divided. Learn about the muscles, nerves, and vessels in each compartment, and their importance in leg functioning.