Compartment syndrome

As a compartment syndrome of the state is defined, in which case the skin and soft tissue envelope is closed, an increased tissue pressure leads to a reduction of tissue perfusion, resulting in neuromuscular disorders or tissue and organ damage result. Most often, the compartment syndrome occurs in the forearm or lower leg. In the ICU, a abdominal compartment syndrome is known, as may occur for example after a rupture of the aorta.

The compartment syndrome caused by increased pressure in the muscle compartments of the forearm or lower leg (hence also the term boxes syndrome ) Damage to the blood vessels, muscles and nerves. By the definition of the muscle groups by rough connective tissue ( fascia), which are hardly extensible, increased pressure leads to circulatory disturbance of the corresponding region and thus to damage to nerves and muscles. A lodge on the lower leg syndrome comes before especially in the tibialis anterior lodge and is then referred to as anterior tibial syndrome or tibial lodges syndrome.

Epidemiology

The compartment syndrome is the second most common complication of lower leg fractures ( after deep vein thrombosis).

Causes

The pressure increase is due to bruising or edema, resulting from direct or indirect trauma to the tissue, such as accidents (eg " dead leg "). This results in a swelling of the area bounded by fascia muscle groups, the compartments or boxes result. This - it only extends to the muscle, not the fascia - the pressure increases in the boxes. The increased pressure leads to a reduced blood supply to the muscles. These poorer blood supply leads to reduced metabolism. In acute compartment syndrome, this then results in the worst case, necrosis of tissue and neuromuscular injury. In chronic compartment syndrome, the risks are not as high as the restriction of the blood flow is lower. Consequently, complaints usually occur only under load and usually without serious consequences.

The compartment syndrome occurs almost exclusively acutely after bone fractures, muscle contusions or during or immediately after excessive load (after long marches ), and also by the excessive strain on the muscles in athletes - goers, middle-distance and marathon runners or triathletes. Here excessive burden on the discomfort is usually responsible: The volume of the muscle increases too quickly. This causes the muscle groups surrounding fascia are not sufficiently adapted to the increased volume. This also leads to an increased pressure in the boxes. In relation to sport as a triggering agent is therefore also spoken by the functional compartment syndrome.

In some cases, very long (more than 5-hour ) operations, such as in the lithotomy position, especially in urology, besides also in gynecology and in very rare cases in visceral surgery cause.

Furthermore, cases are known in which the administration of anticoagulants to prevent blood clotting have favored the occurrence of compartment syndrome. Very rarely will an increase in pressure caused by a bacterial infection, eg as a result of insect bites triggered.

In contrast to the above mentioned forms of the abdominal compartment syndrome is immediately life-threatening for the patient. A distinction is made between a primary and secondary form. A primary compartment syndrome can occur, for example in the course of peritonitis, pancreatitis or Mesenterialinfarkts. The secondary form is due to a surgical procedure.

Clinic and diagnostics

Painful, indurated muscles → muscle strain pain → Spontaneous muscle pain as signs of ischemia → sensory disturbances (late sign). These symptoms are, especially in state after surgery in the lithotomy position or trauma, alarm signals. The diagnosis can by palpation and - provided a pressure probe in the respective compartment - reliable.

An abdominal compartment syndrome has several consequences. Firstly, the return flow of blood to the heart is impaired and preload and therefore cardiac output decrease. Secondly, there is the further course of the patient to breathing problems because of increased abdominal pressure is transmitted through the diaphragm into the chest and compresses the lungs. Thereby higher ventilation pressures are needed to achieve an adequate oxygenation of the blood. The intra-abdominal pressure rise due also next local blood flow disturbances an Funktionseinschräkung of organs such as the liver, pancreas and kidneys. In the intestine may be caused by the impaired blood flow lesions of the intestinal mucosa, can occur on the baktierielle infections and peritonitis. Furthermore, it may lead to hypoperfusion of the brain. To detect an abdominal compartment syndrome, bladder pressure measurement can be performed.

Therapy

In the treatment of compartment syndrome must be made between acute and chronic compartment syndrome or functional. In acute compartment syndrome of the fasciotomy is the treatment of choice: Approval of the compartments affected by emergency even split in the muscle compartments (in the case of the lower leg: Lateral incision of the tibialis anterior Loge and the superficial flexor compartment on the entire lower leg length ) or in the case of the abdomen by emergency even opening the abdomen ( laparotomy ).

By setting presented seams a wide gaping of the wound edges can be avoided and a gradual rapprochement be prepared. The wound is closed by reduction of the swelling usually by secondary suture or split skin grafting. In the area of the abdomen, surgical meshes and cloth transplants can be performed.

In chronic compartment syndrome or functional conservative therapy is applied: cooling, elevation, compression and load reduction of the affected muscles should be applied. An athletic exposure should be avoided accordingly. Usually, however, a training in the aerobic zone with low heart rate is possible and useful also for the healing of the compartment syndrome. The improved blood flow to the muscles, the fasciae are better supplied with nutrients. As long as the muscle metabolism through exercise near the lactate anaerobic zone accumulates no, no symptoms are likely to show. The training should have a total by a low intensity not too burdensome due to excessive training volumes for the muscles.

Complications

Muscle and nerve

The lack or displaced by only a few hours of treatment leads to permanent damage irreparably damaged by the nervous tissue pressure and the tissue can become necrotic and is finally converted fibrotic; This has resulted in paralysis or even the loss of the affected limb. In the forearm, may thus form a typical Volkmann 's contracture, which is characterized by joint stiffness with flexion of the wrist.

Systemic

Due to muscle breakdown and circulation disorders arise partly harmful metabolites that can lead via the blood circulation to serious consequences such as kidney failure.

Skin

After splitting the fascia can may no longer be made direct closure of the skin edges. In these cases, may be necessary to cover with split skin.

History

The first mention of the traumatic compartment syndrome was made in 1881 by the Halle surgeon Richard von Volkmann. Bernhard Bardenheuer considered in 1911 for the first time fasciotomy as a treatment, which, however, only in 1926 by PN Jepson was introduced. 1920 conducted research on Finochietto compartment syndrome of the upper extremity. The current term compartment syndrome was not coined before 1963 by Reszel and employees of the Mayo Clinic.