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Acute Compartment Syndrome (ACS)


Dr. Burrow demonstrating the knee to a patient

John D. Burrow, DO

Orthopaedic injuries that occur during traumatic accidents can be gruesome; however, most are not truly life-threatening. Sometimes, fractures or crush injuries, or even minor injuries, such as those that occur with competitive running, may develop a complication known as acute compartment syndrome or ACS which is a true medical emergency.  In this article, I will discuss ACS, its symptoms, how it is diagnosed and treated.

First, an anatomy lesson.  Our body is comprised of bones, muscles, tendons, ligaments, nerves, blood vessels and other soft tissues.  These are located all over our bodies and are divided into recognized compartments separated by bone and fascia, a kind of connective tissue.  In a healthy compartment, let’s say of the lower leg, everything functions normally and there is a normal interstitial pressure so that circulation in the leg flows freely.  When an injury occurs, the tissues in the closed compartment may swell, compromising circulation and the inward flow of oxygen and nutrients to the cells and the outward flow of toxins.  This can quickly cause irreversible muscle and nerve damage, necrosis, permanent disability and potentially the loss of a limb or life.

The symptoms of ACS are known by the five “P”s, Pain, Paresthesia (numbness or lack of feeling), Pallor (paleness or grey color), Paralysis, and high intra-compartment Pressure.  Notably, at first, the pain is intense and is not relieved by IV narcotic pain medications, nor alleviated by anything other than surgical intervention. In its later stages, pain may be absent as nerve damage increases. It is most frequently seen in the legs but can happen anywhere in the limbs and even in the buttocks.

Diagnosis of ACS can be difficult, even among expert physicians.  This disorder happens ten times more often in men than in women and usually from injury/fracture or after surgery.  As physicians, we also remember the five “P”s, as well as collect information about the patient’s medical history, how recently the trauma occurred and do a detailed physical examination of the affected body part. 

If a splint or cast is in place, then the first order of business is to remove the cast and or monitor the symptoms to see if that resolves the problem.  If symptoms persist, a surgical procedure called a fasciotomy may be required to open the compartment to relieve the intense pressure within and to restore the circulation to the tissues.

Fasciotomy will be performed under general or regional anesthesia in an inpatient hospital operating room.  Long, lengthwise incisions will be made in the affected body compartment to allow for pressure and fluid release and to restore circulation. If fasciotomy is required, inpatient and/or outpatient rehabilitation may be needed with the ultimate goal of increasing strength, stamina, ROM and function. 

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