Makindo Medical Notes

📖 About

• 🚨 Acute Compartment Syndrome (ACS) = orthopaedic emergency requiring immediate fasciotomy.
• ❌ If untreated, leads to irreversible muscle & nerve necrosis, limb contractures, rhabdomyolysis, renal failure, or amputation.
• ⏳ Critical window: ~6 hours before permanent damage occurs.

💡 Clinical pearl: Pain out of proportion + pain on passive stretch = the most reliable early signs.

⚙️ Pathophysiology

• 📈 Trauma or swelling raises intracompartmental pressure within a rigid fascial boundary.
• 🩸 Capillary perfusion pressure drops → muscle ischaemia → oedema → further ↑ pressure → vicious cycle of tissue hypoxia.
• ⚠️ Nerve injury occurs earlier than muscle necrosis (ischaemic neuropathy).

📌 Causes

• 🦴 Fractures (tibia, forearm = most common).
• 🤕 Soft tissue trauma (crush injuries, contusions, reperfusion after ischaemia).
• 🩸 Vascular injury/bleeding (trauma, surgery, anticoagulation).
• 🩻 External compression (tight casts, splints, bandages, prolonged positioning).
• 🔥 Circumferential burns causing restrictive eschar.

🩺 Clinical Presentation

• 😣 Severe, progressive pain, disproportionate to injury.
• ↔️ Pain exacerbated on passive stretch (e.g., dorsiflexing toes with tibial fracture).
• 🔔 Tense, “wood-like” compartment on palpation.
• Late signs: paraesthesia, paralysis, pallor, pulselessness → indicate irreversible damage.

📝 5 Ps (but remember only Pain is early): Pain ✅ | Paraesthesia ❌ | Paralysis ❌ | Pallor ❌ | Pulselessness ❌

🧾 Differentials

• Arterial occlusion (embolus, thrombosis).
• Deep vein thrombosis (DVT).
• Severe cellulitis/myositis.
• Peripheral neuropathy (e.g., diabetic foot pain).

🔎 Investigations

• 🔍 Clinical diagnosis — do not delay.
• 📊 Compartment pressure monitoring:
  • >30 mmHg = diagnostic threshold.
  • ΔP (diastolic BP – compartment pressure) <30 mmHg also significant.
• 🧪 Bloods: CK & myoglobin (to assess rhabdomyolysis), U&E for AKI risk.

⚡ Management

• 📞 Immediate orthopaedic referral — time-critical.
• 🔓 Remove external compression: split casts, dressings.
• 💨 O₂ + 💧 IV fluids to optimise tissue perfusion.
• 🔪 Emergency fasciotomy: release all compartments at risk (commonly 4 in the leg, 2 in forearm).
• 🩹 Post-op: leave wounds open, apply VAC dressings; may need delayed closure or skin grafting.

🌟 Key takeaway: A present pulse does not rule out ACS — always trust pain + passive stretch. Document neurovascular exams regularly.