COMPARTMENT SYNDROME

Increased compartment pressure is commonly caused by:

The most common areas involved are the anterior and deep posterior compartment of the leg and the volar forearm compartment. Other areas include the thigh, the dorsal forearm, the foot, the dorsal hand and, rarely, the buttocks.

Diagnostic physical findings include:

Treatment

Split the cast and dressings, if present. Do not elevate the limb, but observe carefully for improvement. If signs and symptoms persist, treat the acute compartment syndrome with immediate surgical decompression.

Even short delays will increase the extent of irreversible muscle necrosis so, if you suspect a compartment syndrome, proceed with the decompression immediately.

Techniques

Leg

1	Use two full length incisions to decompress the four leg compartments (Figures 18.79 and 18.80).
Figure 18.79
Figure 18.80
2	Place one incision on the anterior lateral aspect of the leg just anterior to the fibula. Divide skin and the fascia surrounding the anterior and lateral compartments.
3	Place the second incision 1–2 cm posterior to the medial border of the tibia to access the superficial and deep posterior compartments (Figure 18.81).
Figure 18.81

Forearm

1	Decompress the superficial and deep volar compartments through a single incision beginning proximal to the elbow and extending across the carpal canal (Figure 18.82).
Figure 18.82
2	Divide the superficial fascia for this entire length, being sure to open the carpal canal to decompress the median nerve. Expose the deep compartment muscles and incise the fascia surrounding the pronator teres, the pronator quadratus, the flexor digitorum and the flexor pollicis longus muscles (Figure 18.83).
Figure 18.83
3	Inspect the muscles for signs of necrosis. Dead muscle has a dark purple colour, does not bleed if cut, does not twitch if pinched and has a flabby consistency. Remove obviously dead muscle but, if in doubt, leave it and re-evaluate in 1–2 days. Do not close the wound.
4	Apply sterile dressings and splint the extremity. If there is an associated fracture, apply an external fixation apparatus, traction or a cast. Return the patient to the operating theatre for re-debridement in 1–2 days. When the wound is clean and the swelling has decreased sufficiently, close the wound or apply a split thickness skin graft.

FAT EMBOLISM SYNDROME

Fat embolism syndrome follows major long bone trauma. The etiology remains elusive, but seems to involve a showering of bone marrow contents into the bloodstream. These lodge in the lungs, brain and other organs. The syndrome becomes clinically evident on the second or third day post injury. The lung involvement causes respiratory distress, which is fatal in a small percentage of patients.

Signs include:

Treatment

The syndrome is self-limited, lasting usually just a few days. Permanent effects are rare, but include impaired vision, kidney abnormalities and mental changes.