Fuad Iqbal Elka Putra, Hanifah Hanum I Compartment Syndrome of The Lower Limb : Diagnosis, Anatomy and Treatment

Compartment Syndrome of The Lower Limb :

Diagnosis, Anatomy and Treatment
Fuad Iqbal Elka Putra1, Hanifah Hanum2
1General Practitioner, Cileungsi Regional Hospital, Bogor, West Java, Indonesia
2General Practitioner, Kartika Hospital, East Jakarta, DKI Jakarta, Indonesia

Abstract
Acute compartment syndrome (ACS) is an orthopaedic emergency that can threaten life and limb. A comprehensive
understanding of anatomy, along with proper diagnosis and treatment, plays a crucial role in preventing lower limb ischemia.
We conducted an updated review of the literature using digital databases such as PubMed, Springer Link, and Science Direct.
A clinical diagnosis of compartment syndrome must be followed by surgical decompression. Clinical signs of ACS include the
6 P’s: pain, poikilothermia, pallor, paresthesia, pulselessness, and paralysis. This literature review revealed that some studies
showed fasciotomy is an emergency surgical procedure performed to decompress a compartment. The most common and
validated method to measure limb intracompartment pressure (ICP) is by using the handheld Stryker Intra-Compartmental
Pressure (STIC) Monitor System. Lower leg compartment divided into anterior, lateral, superficial posterior and deep
posterior compartment, inside of compartment there are muscle, nerve, artery and vein. After diagnosis compartment
syndrome we should continue to surgical decompression by fasciotomy in two methode medial incision (deep and superficial
posterior compartment) and lateral incision (anterior and lateral compartments). The time limit for fasciotomy is within 8
hours or within one hour for compartment pressure 40mmHg. Early fasciotomy had a lower limb amputation rate comparison
with delayed fasciotomy (8.5% vs 24.6%, p>0.001). As a conclusion early recognition and diagnosis of conditions of
compartment syndrome are essential in preventing lower limb ischemia.

Keywords: Acute compartment syndrome, intracompartmental pressure, lower extremity

Kompartemen Sindrom Ekstremitas Bawah : Diagnosis, Anatomi dan

Tatalaksana
Abstrak
Kompartemen sindrom akut (SKA) merupakan keadaan darurat di bidang ortopedi yang dapat mengancam jiwa dan anggota
gerak. Pemahaman yang komprehensif terhadap anatomi, bersama dengan diagnosis dan pengobatan yang tepat,
memainkan peran penting dalam mencegah iskemia anggota gerak bawah. Kami melakukan tinjauan literatur terbaru dengan
menggunakan basis data digital seperti PubMed, Springer Link, dan Science Direct. Diagnosis klinis dari sindrom kompartemen
harus diikuti dengan dekompresi bedah berupa fasiotomi. Tanda-tanda klinis SKA meliputi 6P: pain, poikilothermia, pallor,
paresthesia, pulselessness, and paralysis. Tinjauan literatur ini mengungkapkan bahwa beberapa studi menunjukkan bahwa
fasiotomi merupakan prosedur bedah darurat yang dilakukan untuk mendekompresi kompartemen. Metode paling umum
dan tervalidasi untuk mengukur tekanan intrakompartemenpada anggota gerak adalah dengan menggunakan Sistem
Monitor Tekanan Intra-Kompartemen Stryker. Kompartemen kaki bagian bawah dibagi menjadi kompartemen anterior,
lateral, superficial posterior, dan deep posterior. Di dalam kompartemen terdapat otot, saraf, arteri, dan vena. Setelah
diagnosis sindrom kompartemen tegak, studi menunjukkan harus segera dilakukan dekompresi bedah melalui fasiotomi
dengan dua metode, yaitu insisi medial (kompartemen posterior dalam dan permukaan) dan insisi lateral (kompartemen
anterior dan lateral). Batas waktu untuk fasiotomi kurang dari 8 jam, atau dalam waktu 1 jam jika tekanan kompartemen
mencapai 40mmHg. Fasiotomi yang dilakukan sejak awal menurunkan angka amputasi anggota gerak jika dibandingkan
dengan fasiotomi yang dilakukan terlambat (8.5% vs 24.6%, p>0.001). Sebagai kesimpulan, pengenalan dan diagnosis dini
kondisi sindrom kompartemen menjadi hal penting dalam mencegah iskemia anggota gerak bawah.

Kata kunci: Ekstremitas bawah, kompartemen sindrom akut, tekanan intrakompartemen

Korespondensi : Fuad Iqbal Elka Putra, alamat Jl. Masjid Al-Umar no 77, Lubang Buaya, Cipayung, Bandar Lampung, email :
[email protected]

Introduction
Acute compartment syndrome (ACS) is a trauma, vascular or crush injuries, and prolonged
surgical emergency that can threaten life and periods of immobility.1 In cases where a
limb. Additionally, lower extremity compartment comprehensive physical examination is not
syndrome often occurs in cases involving high- feasible, intramuscular compartment pressure
energy mechanisms of injury. However, it's measurements can serve as a valuable additional
crucial to maintain a high index of suspicion even diagnostic tool, although serial physical
in situations involving low-energy or penetrating examinations conducted by an experienced

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Fuad Iqbal Elka Putra, Hanifah Hanum I Compartment Syndrome of The Lower Limb : Diagnosis, Anatomy and Treatment

provider are still considered the gold standard for Results

accurate diagnosis2. Unlike many Compartment syndrome occurs when the
musculoskeletal conditions, compartment pressure within a defined compartmental space
syndrome presents a greater challenge in terms increases past a critical pressure threshold,
of accurate diagnosis rather than treatment. thereby decreasing the perfusion pressure to
Prompt performance of fasciotomies, releasing that compartment. The commonest cause of all
all affected muscular compartments, is crucial in ACSs are tibial shaft fractures with a range from
preventing life- and limb-threatening 2-9%. After the leg, the next commonest location
consequences associated with a missed is in the forearm, but almost any compartment
compartment syndrome.1,2 can be affected: arm, thigh, foot, buttock, hand,
Compartment syndrome arises when the and abdomen.6 Any internal or external etiology
pressure within a specific compartment can increase intra-compartmental pressure
surpasses a critical threshold, leading to a cause acute compartment syndrome. Trauma is
reduction in perfusion pressure within that the most likely precipitating facator, with
compartment. In general, longer durations of fracture leading the greatest number of cases of
compartment syndrome and tissue ischemia are compartment syndrome. Some of the etiology
associated with poorer outcomes. Ischemia are : fracture, crush injury, injection injury,
lasting only 1 hour can result in reversible penetrating trauma, constrictive dressings,
neuropraxia, while ischemia lasting 4 hours can casting, burns, infection, bleeding disorders,
lead to irreversible axonotmesis. Ischemia lasting arterial onjury, reperfusion and extravasation of
up to 6 hours is associated with irreversible drugs.6,7
necrosis and a higher likelihood of causing Acute compartment syndrome is a clinical
functional impairment.2 diagnosis, the most important determinant of
The anterior compartment contains the ouctome is early recognition and emergency
tibialis anterior, extensor hallucis longus, surgical intervention. Classically the signs of
extensor digitorum longus, innervated by the acute compartment syndrome include the 6 ‘P’s’
deep peroneal nerve and supplied by the anterior : pain, parasthesia, poikilothermia, pallor,
tibial artery. The anterior compartment muscles paralysis, and pulselessness. Pain is the most
function as the primary extensors of the ankle common and the initial complaint and should
(dorsiflexion) and extensors of the toes.3 The trigger the workoup of diagnosis of acute
Lateral compartment contains Peroneus Longus compartment syndrome.7 A clinical diagnosis of
and Peroneus Brevis, innervated by Superficial compartment syndrome must be followed by
peroneal nerve and supplied by peroneal artery.4 surgical decompression, however the diagnosis is
The posterior compartment of the leg often unclear; and pressure monitoring is
(often referred to as the "calf") further divides commonly required. Due to its subjective nature,
into superficial and deep compartments by the the absence of pain, although unlikely, does not
transverse intermuscular septum. The larger, eliminate the possibility of compartment
superficial compartment of the lower leg syndrome. Several case have documented where
contains the gastrocnemius, soleus (GS) and patients with acute compartement syndrome did
plantaris muscles. The deep layer of the leg's not experience pain.8
posterior compartment contains the popliteus, All characteristics of the six P's may not be
flexor digitorum longus (FDL), flexor hallucis present in every individual. Furthermore,
longus (FHL), and tibialis posterior (TP) muscles. 5 presentation of these symptoms will vary
A missed diagnosis of compartment syndrome is depending on time that has lapsed since the
important because of direct morbidity to the initial pressure began to rise, the rate of ICP
patient and because it creates a high-risk increase, blood pressure, and damage within the
medical-legal environment for the provider.5 This compartment. Pain 8,9 As acute compartment
review article aims to know the definition, syndrome (ACS) advances, the affected extremity
diagnosis anatomy, and treatment of lower leg undergoes edema and becomes tense. This leads
posterior compartment syndrome. to increased pressure on nerve fibers and injured
structures within the compartment.

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Fuad Iqbal Elka Putra, Hanifah Hanum I Compartment Syndrome of The Lower Limb : Diagnosis, Anatomy and Treatment

The rise in ICP leads to ischemia of neuronal

tissues, resulting in nerve dysfunction and the
development of paresthesia, followed by paresis
and ultimately paralysis. Paresthesia may
manifest within 30 minutes after nerve injury,
while motor function deterioration can occur
within four hours of muscle tissue ischemia.
Functional losses, once ischemia persists for
eight to 24 hours, may become irreversible. In
cases of increased pressure on the deep peroneal
nerve, the loss of light touch sensation often
precedes limb weakness. Light touch assessment
can be performed using two-point discrimination
or pin prick testing. Poikilothermia refers to a
Figure 1. The Stryker Intra-Compartmental Pressure change in temperature or the presence of
(STIC) Monitor System.2,6,7 coolness in the affected extremity. Williams et
al. found a rate of infection of 28% when
Pain is typically described as fasciotomy was delayed more than twelve
disproportionate to the injury, especially during hours6.
passive stretching. Normal resting limb ICP is 0-4
Pulselessness and pallor 8,9 are observed as mmHg.6 With exertion, typical limb ICP may
late findings in acute compartment syndrome increase up to10 mmHg.6 With ACS, an ICP of 30
(ACS). Pulselessness is not a reliable indicator of mmHg or above is considered critical and
ACS, while pallor is less frequently observed. In treatment with emergent surgical
the early stages of ACS, arterial insufficiency is decompression should be considered. The most
atypical, and both the dorsalis pedis and common and validated method to measure limb
posterior tibial pulses can be palpated. Capillary ICP is by using the handheld Stryker Intra-
refill is rapid, and the affected extremity usually Compartmental Pressure (STIC) Monitor System.
8
appears pink. However, as the (Figure 1; Stryker Instruments, Kalamazoo,
intracompartmental pressure (ICP) continues to MI)2,6,7.
rise, the loss of limb pulses and the development
of pallor indicate compression of arterial
perfusion.

Figure 3. Four-compartment fasciotomy of the right leg

through two incisions. The lateral incision
decompresses the anterior and lateral compartments,
and the medial incision decompresses the superficial
and deep posterior compartment.2

Figure 2. Cross-section of the lower leg depicting the 4 The lower leg divides into 4 compartments :
compartments and select key structures.7 Anterior, Lateral, Superficial Posterior and Deep
Paresthesia and paralysis 8,9 are observed Posterior compartments (figure 2). Each
as ICP (intracompartmental pressure) increases. compartment contains specific nerves, arteries

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Fuad Iqbal Elka Putra, Hanifah Hanum I Compartment Syndrome of The Lower Limb : Diagnosis, Anatomy and Treatment

and veins, muscles, and bony structures that with which has been extensively documented in the
injury contribute to the unique clinical literature. The lateral incision is performed to
presentations in ACS. Knowledge about the most decompress the anterior and lateral
important structures (table 1) within these compartments, while the medial incision is made

Table 1. Key structures within the lower leg compartments7.

Compartment Muscle Artery/Vein Nerve
Anterior Extensor Muscle : Anterior tibial Deep Peroneal
• Tibialis Anterior
• Extensor Hallucis Longus (EHL)
• Extensor Digitorum Longus (EDL)
Lateral • Fibularis Longus Peroneal Superficial Peroneal
• Fibularis Brevis
Superficial Posterior Superficial Flexor : Posterior Tibial Tibial
• Soleus
• Gastrocnemius
• Plantaris
Deep Posterior Deep Flexor: Posterior tibial and Tibial
• Tibialis Posterior Peroneal
• Flexor Hallucis Longus (FHL)
• Flexor Digitorum Longus (FDL)

compartments is critical to efficiently assess and to decompress the superficial and deep posterior
diagnose physiologic changes in ACS that compartments (refer to figure 3).2 It is crucial to
contribute to pathologic development.7 perform a complete fasciotomy to ensure
optimal outcomes.2 Incomplete fasciotomies do
Treatment not sufficiently release the affected muscular
Immediate management of acute compartment, contribute to ongoing
compartment syndrome involves identifying and compartment syndrome, and result in poorer
removing any external compressive forces. outcomes.10 A retrospective analysis of 612
Additionally, casts or dressings should be patients who faced early and delayed surgical
released down to the skin to relieve pressure. It decompression (<8 hours or >8 hours)
is important not to elevate the limb, but rather fasciotomy showed a patient with early
keep it at the level of the heart. Elevating the limb fasciotomy had a lower limb rate amputation
further can potentially decrease arterial flow and (8.5% vs 24.6% P>0.001). The author suggest to
exacerbate the condition.2,7 Acute compartment perform fasciotomy at the time vascular repair.
syndrome need emergency surgical The other author found patient who faced
decompression, the time limit for fasciotomy is delayed fasciotomy resulted in higher
within 8 hours from the diagnosis of acute amputations rate within 30 days (50% vs 5.9%,
compartment syndrome. If the clinical symptoms p=0.002).11
obviously appeared and the measurement of The lateral incision is made from the tibial
compartment pressure higher than 40mmHg, tuberosity to just above the lateral malleolus.
surgical decompression should be done within an The incision is continued through the
hour. The author suggest non-operative subcutaneous tissue, and a fasciotomy is
management for a late case presentation or performed to enter the anterior
missed diagnosis of acute compartment compartment. The medial incision is made two
syndrome, because it asscociated with higher risk fingerbreadths posterior to the tibia from just
of infection. But, in these situations, case by case distal to the knee to just proximal to the medial
evaluation is mandatory. malleolus. Again, the incision is carried through
The conventional treatment for lower the subcutaneous tissue, without injuring the
extremity compartment syndrome involves a saphenous vein. The superficial posterior
two-incision, four-compartment fasciotomy, compartment is opened first. The deep posterior

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Fuad Iqbal Elka Putra, Hanifah Hanum I Compartment Syndrome of The Lower Limb : Diagnosis, Anatomy and Treatment

compartment is entered by taking the soleus pulselessness, and poikilothermia), along with
muscle off of the posterior edge of the tibia.12 maintaining a high clinical suspicion. Fasciotomy
If the clinical manifestations of acute should be performed less than 8 hours and within
compartment syndrome (ACS) do not improve an hour for compartment pressure 40mmHg to
with initial interventions, immediate surgical lower limb amputation rate.
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