Compartment syndrome; causes, symptoms and their physiotherapy management

Compartment Syndrome—Definition, Pathophysiology, Diagnosis, and Physiotherapy Management

🔹 Introduction

Compartment Syndrome (CS) is a serious, potentially limb- and life-threatening condition caused by increased pressure within a closed osteofascial compartment. This pressure impedes blood flow and tissue perfusion, resulting in ischemia, neuromuscular damage, and if untreated, necrosis of muscles and nerves.

Each limb contains several muscle compartments surrounded by inelastic fascia. The fascia maintains compartment shape and pressure under normal conditions, but it cannot expand when internal pressure rises. When the internal pressure surpasses capillary perfusion pressure, oxygen delivery stops, leading to irreversible tissue death within hours.

compartment syndrome


🔹 Epidemiology

  • Incidence: Approximately 3.1 cases per 100,000 population annually.

  • Age group: Common in young males (under 35 years) due to higher trauma rates.

  • Common sites:

    • Lower limb: Anterior compartment of the leg (most frequent).

    • Upper limb: Volar compartment of the forearm.

  • Onset:

    • Acute (within hours after trauma or surgery).

    • Chronic (gradual, with repetitive exercise or overuse).

Causes and Risk Factors

  • Fractures (especially tibial or forearm fractures)

  • Crush or blunt trauma

  • Tight casts or bandages

  • Severe burns or reperfusion injury

  • Intense exercise or overuse injuries

  • Anticoagulant therapy (leading to bleeding into the compartment)

🔹 Pathophysiology (Mechanism of Injury)

The pathophysiology of compartment syndrome can be understood through the following sequence:

  1. Initial Event:

    • Trauma, fracture, crush injury, bleeding, or tight external compression (cast, splint).

  2. Increase in Compartment Pressure:

    • Accumulation of blood, interstitial fluid, or edema raises intracompartmental pressure.

  3. Vascular Compromise:

    • Rising pressure compresses small veins first (due to their thin walls), reducing venous outflow.

  4. Decreased Arteriovenous Gradient:

    • Venous congestion further elevates tissue pressure, causing arterial inflow reduction.

  5. Ischemia:

    • Reduced oxygen and nutrient delivery to muscles and nerves.

  6. Cellular Death:

    • Within 4–6 hours, muscle and nerve necrosis can become irreversible, leading to contractures or limb loss.

🔹 Types of Compartment Syndrome

1. Acute Compartment Syndrome (ACS)

  • A surgical emergency.

  • Typically follows fractures (especially tibial and forearm), crush injuries, or revascularization after ischemia.

  • Rapidly progressing pain and swelling are key signs.

  • Fasciotomy is the only definitive treatment.

2. Chronic (Exertional) Compartment Syndrome (CECS)

  • Caused by repetitive muscle use such as running or jumping.

  • Symptoms develop gradually during exercise and subside after rest.

  • Common in athletes and soldiers.

  • Managed conservatively, but resistant cases may need surgical decompression.

🔹 Etiology / Causes

Intrinsic causes (within the compartment):

  • Fractures (especially tibial, supracondylar, or forearm)

  • Crush or penetrating injuries

  • Muscle rupture or hemorrhage

  • Vascular injury → bleeding or reperfusion edema

  • Prolonged limb compression (coma, unconsciousness, tight tourniquet)

Extrinsic causes (outside the compartment):

  • Tight casts, splints, bandages, or surgical dressings

  • Burns (causing circumferential eschar)

  • Venous obstruction (tight garments or bandages)

🔹 Clinical Features

The Classic “6 Ps” of Compartment Syndrome:

  1. Pain:

    • Severe, deep, unrelenting pain out of proportion to the injury.

    • Increases with passive stretching of involved muscles.

  2. Paresthesia:

    • Tingling or burning sensation due to nerve ischemia.

  3. Pallor:

    • Pale skin from reduced perfusion.

  4. Paralysis:

    • Loss of motor function due to prolonged ischemia.

  5. Pulselessness:

    • Late sign; indicates severe vascular compromise.

  6. Poikilothermia:

    • Limb feels cooler compared to the unaffected side.

⚠️ Early warning signs: Pain and paresthesia.
Late signs: Paralysis, pulselessness, and pallor.

🔹 Diagnosis

1. Clinical Evaluation

  • Pain disproportionate to the injury, worsened by passive stretch.

  • Tense, hard compartment on palpation.

  • Neurological signs (numbness, weakness).

  • Diminished distal capillary refill.

2. Intracompartmental Pressure Measurement

  • Measured using a needle manometer or wick catheter.

  • Normal: <10 mmHg

  • Critical Pressure: >30–40 mmHg

  • ΔP (Delta Pressure): Diastolic BP – Compartment Pressure

    • If ΔP < 30 mmHg, fasciotomy is indicated.

3. Imaging

  • MRI or ultrasound may help in chronic cases to visualize muscle swelling but are not used in acute emergencies.

🔹 Medical and Surgical Management

1. Emergency Management

  • Remove constrictive materials (casts, bandages, dressings).

  • Position the limb at heart level (not elevated) to maintain perfusion.

  • Administer oxygen and IV fluids to ensure adequate tissue oxygenation.

  • Immediate fasciotomy if pressure is high or symptoms worsen.

2. Surgical Management (Fasciotomy)

  • Gold standard treatment for acute compartment syndrome.

  • All affected compartments are opened through long skin incisions to release pressure.

  • Wound is left open with delayed closure or skin grafting once swelling subsides.

3. Post-operative Care

  • Pain management

  • Infection control

  • Dressing and wound care

  • Physiotherapy rehabilitation (detailed below)

🔹 Physiotherapy Management

Physiotherapy plays a crucial role in restoring muscle strength, joint mobility, and functional independence after compartment syndrome or fasciotomy.

Phase 1: Acute Phase (0–2 Weeks Post-Fasciotomy)

Goals:

  • Reduce pain and swelling

  • Prevent contractures and joint stiffness

  • Maintain cardiovascular and respiratory function

Treatment:

  • Positioning: Limb at heart level to improve circulation.

  • Gentle Active/Passive ROM: For adjacent joints (e.g., knee, ankle, shoulder).

  • Isometric Exercises: For unaffected muscle groups.

  • Cryotherapy: To minimize pain and edema (avoid directly on open wounds).

  • Deep Breathing & Circulatory Exercises: To prevent pulmonary complications and DVT.

  • Wound Care Education: Proper hygiene and infection prevention.

Phase 2: Sub-acute Phase (2–6 Weeks)

Goals:

  • Regain joint range and muscle flexibility

  • Prevent scar adhesions

  • Gradually restore weight-bearing

Treatment:

  • Active ROM & Gentle Stretching: As pain allows.

  • Scar Mobilization: Once wound healing permits, to prevent fibrosis.

  • Progressive Strengthening: Using resistance bands or light weights.

  • Gait Training: If lower limb involved; partial weight-bearing → full weight-bearing progression.

  • Electrical Stimulation (FES): To maintain muscle activity in weak muscles.

  • Hydrotherapy: For gentle mobilization and relaxation.

Phase 3: Functional / Chronic Phase (6–12 Weeks and Beyond)

Goals:

  • Restore strength, endurance, and proprioception

  • Improve functional performance and return to sport or work

Treatment:

  • Advanced Strength Training: Closed-chain and plyometric exercises.

  • Proprioceptive & Balance Training: Using wobble boards, balance pads.

  • Functional Training: Task-specific exercises (e.g., running, climbing, lifting).

  • Aerobic Conditioning: Low-impact cardio like cycling or swimming.

  • Education:

    • Early recognition of recurrence

    • Avoiding tight bandages or overtraining

    • Importance of gradual load progression

🔹 Complications

If untreated or delayed:

  • Volkmann’s Ischemic Contracture (especially in forearm)

  • Muscle fibrosis and atrophy

  • Nerve palsy (peroneal, median, or ulnar)

  • Permanent disability or amputation

  • Chronic pain syndrome

🔹 Prevention

  • Avoid tight casts or dressings post-injury.

  • Regular neurovascular checks after fractures or surgery.

  • Educate patients about warning signs (pain, numbness, tightness).

  • Ensure proper hydration and gradual training in athletes.

  • Early decompression in high-risk trauma cases.

🔹 Prognosis

  • If treated within 4–6 hours → excellent recovery.

  • Delay beyond 12 hours → permanent muscle or nerve damage.

  • With timely fasciotomy and rehabilitation, most patients regain 80–100% function.

🔹 Conclusion

Compartment Syndrome is a surgical emergency that demands prompt recognition and decompression to save the limb. Physiotherapy is vital in every recovery stage—improving muscle function, preventing contractures, and restoring mobility.
Awareness among healthcare professionals and patients ensures early intervention, minimizing long-term complications and disability.

🔹 References

  1. Matsen FA, et al. Compartmental Syndromes and Volkmann’s Contracture. New England Journal of Medicine, 1980.

  2. Mubarak SJ, Hargens AR. Acute Compartment Syndromes. Surgical Clinics of North America, 1983.

  3. Whitesides TE Jr. Tissue Pressure Measurements as a Determinant for Fasciotomy. Clinical Orthopaedics & Related Research, 1975.

  4. Rorabeck CH. The Management of Compartment Syndromes of the Leg. JBJS, 1984.

  5. Physiopedia. Compartment Syndrome.


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