Compartment Syndrome in the Extremities

Compartment syndrome is often an underestimated problem within trauma and reconstructive surgery. Compartments in the extremities comprise muscles, vessels and nerves surrounded by a non-elastic fascia and bone. As soon as pressure increases through oedema and/or bleeding, the structures inside the compartment become devoid of oxygenation, leading to ischaemia and necrosis. The symptoms are classically pain, pallor, pulselessness, paraesthesias and paralysis ('the five P's'). Diagnosis is made predominantly clinically. Pain and paraesthesias are the most common symptoms, although pain may be underestimated when patients are on extensive pain medication. If compartment syndrome is suspected, surgical release is the first choice therapy. A missed compartment syndrome can result in a Volkmann's ischaemic contracture, which may lead to devastating impairment of motor function and sensibility. In the lower extremity the anterior compartment is the most affected. In the foot ischaemic contracture often leads to toe contractures. Treatment in ischaemic contracture varies depending on severity, ranging from conservative splinting through excision of fibrous tissue, neurolysis, tenolysis, proximal 'muscle slide', tendon lengthening, tendon transfers and nerve grafting to free vascularized, innervated musculocutaneous flaps. In patients with poor hand function and extensive infarction diagnosed by MRI, we advise debridement, neurolysis and tenotomy, followed in a second stage by a free vascularized innervated muscle transfer with or without nerve grafts. In the lower limb mostly tendon transfers are performed following loss of the anterior compartment.

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