![]() ![]() The common peroneal nerve becomes subcutaneous behind the head of the fibula, before penetrating the posterior intermuscular septum, and becomes closely opposed to the periosteum of the proximal fibula, after which it divides into superficial and deep peroneal nerves. The compartment is bound by the posterior tibia, fibula, and interosseous membrane in the proximal two thirds of the leg. The deep posterior compartment contains the posterior tibial, flexor digitorum, and flexor halluces longus muscles, as well as the posterior tibial nerve and artery, which control plantar flexion of foot. The deep posterior and anterior compartments of the lower leg are commonly missed, potentially resulting in neurovascular compromise. Patterns of injury prone to the development of elevated compartment pressures include venous injury, restoration of perfusion after prolonged ischemia (>3 hours), crush or soft-tissue injury, and large volume resuscitation, all of which increase extremity edema in the postinjury period.įailure to Release Extremity Compartmentsįamiliarity with limb anatomy is necessary to ensure all compartments have been adequately opened. A high index of suspicion or anticipation for the development of compartment syndrome should be maintained with a low threshold to perform fasciotomy. The time during which nerve and muscle are exposed to elevated compartment pressures correlates with tissue damage and is eventually irreversible. Nonetheless, normal pressures in the presence of a consistent clinical examination does not reliably exclude compartment syndrome, and fasciotomy should be performed. Compartment pressures greater than 30 mm Hg or greater than 20 mm Hg below diastolic blood pressure are suggestive of compartment syndrome. Palpable pulses may be present in the setting of a compartment syndrome. Paresthesias are a relatively late and ominous finding. Decreased sensation on the dorsum of the foot over the first web space is also consistent with compartment syndrome because of injury to the deep peroneal nerve, which courses within the anterior compartment. An early indicator of compartment syndrome is pain on palpation of the anterior compartment, as well as anterior compartment pain elicited on passive dorsiflexion of the ankle. In the lower extremity, the anterior compartment if often the first compartment to be affected. However, the most reliable indicator is pain, which is commonly aggravated on passive stretch of the affected muscle groups. The clinical diagnosis of compartment syndrome may be noted in the presence of pain out of proportion to examination, paresthesias, pallor, paralysis, and poikilothermia. Prophylactic fasciotomy is most often performed after restoration of blood flow to an extremity that has been ischemic for 3 or more hours, in the presence of concomitant major venous injury, after repair of vascular injury with associated soft-tissue or nerve injury, following reduction and fixation of long bone fractures with severe crush injury, in the setting of an electrical injury, or when the mechanism of injury places a patient at high risk but serial clinical examination cannot be performed because of brain injury, the need for mechanical ventilation, or evacuation to another facility.Ī therapeutic fasciotomy is performed after the diagnosis of compartment syndrome is established by clinical findings or through direct measurement of compartment pressures. For example, a prophylactic fasciotomy can be performed at the time of a severe crush injury or immediately after restoration of blood flow to a severely ischemic extremity. In 1975 Whitesides and colleagues reported the development of a needle manometer to measure tissue compartment pressures as an adjunctive tool for determining the need for fasciotomy.įasciotomy may be performed either prophylactically in an extremity at high risk for compartment syndrome or therapeutically in the presence of an established compartment syndrome. ![]() ![]() The first reported treatment of compartment syndrome was described by Petersen in 1888, and in 1926 Jepsen was the first to demonstrate an experimental model of ischemic contracture. In 1881 Volkmann was the first to describe acute limb compartment syndrome when he noted the development of contracture as a common sequela after application of tight bandages to an extremity. Compartment syndrome is most often observed after reperfusion of an acutely ischemic extremity or among patients who present after severe limb trauma with associated soft-tissue and orthopedic injuries leading to elevated compartment pressures, compromised venous and arterial circulation, and direct barotrauma. Fasciotomy is designed to prevent nerve injury and myonecrosis resulting from compartment syndrome characterized by elevated pressure within a fixed extremity compartment. ![]()
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