Management of Compartment Syndrome and Crush Syndrome

Abstract

Compartment syndrome and crush syndrome are two closely related clinical entities. Both arise as a consequence of trauma to muscle, which results in swelling and a compromised circulation to muscles and nerves at the microvascular level. If reperfusion of the tissue isn’t restored as quickly as possible, then tissue ischaemia may culminate in cell death and the crippling wholesale loss of muscle compartments. It may be useful to think of compartment syndrome in terms of a localised problem within an osteo-fascial muscle compartment. This is characterised by relentlessly worsening pain in the injured limb. The only effective treatment is fasciotomy which decompresses the ischaemic muscle, allowing it to be reperfused and so rescuing it from death. Fasciotomy is an emergency procedure!

Crush syndrome may arise as a result of a neglected compartment syndrome or directly from severe injury. In crush syndrome the products of muscle cell damage lead to systemic problems which manifest as hyperkalaemia, acidosis, myoglobinuria, and renal failure. When a patient is freed from limb entrapment, reperfusion initiates this process; the most urgent danger is from hyperkalaemia leading to cardiac dysrhythmias and sudden death. Amputation can be life-saving if there are no means or resources to medically manage the hyperkalaemia and later renal failure. The decision whether to perform fasciotomies in crush syndrome is determined by the duration of ischaemia. If this is greater than 6–8 h, the muscle will not be rescued. The patients’ compartments should be left closed, provided the life-threatening metabolic consequences of hyperkalaemia and myoglobinuria can be managed medically. If not, amputation should be performed swiftly.