Compartment Syndrome

Leonie Millard
Leonie Millard

Published: February 28th, 2022

7 min read

What is compartment syndrome?

This is a limb threatening condition that is usually associated with fractures, mainly of the tibia - more commonly known as the shinbone.

What problems can arise?

If treatment is delayed or missed it can lead to significant long-term problems. Compartment syndrome occurs when too much pressure builds up in an enclosed compartment within the body and the condition usually develops quickly after injury (usually a few hours).

It usually occurs because of swelling or bleeding following injury. This increased pressure can be caused by bleeding, swelling or a tight cast, which acts to reduce the space within the compartment. Once this intercompartmental pressure reaches a threshold, it affects the blood flow in the limb leading to severe pain. If prolonged, the tissues are deprived of their blood supply and can be irreparably damaged.

If it is left untreated, this can cause loss of body function and amputation. It requires emergency attention and intervention.

Risk factors

It is more common in men than women. Age is an important risk factor in the development of compartment syndrome, with people below the age of 35 years being much more likely to develop the condition. The condition can also develop in children, but the presentation can be very different to that seen in adults.

Nearly 70% of compartment syndrome cases are due to fractures with the tibia being the most common. The remaining cases are usually from soft tissue injuries. We have also seen it diagnosed in body builders injecting steroids.

There is also a significant risk of compartment syndrome in intubated patients or those with a lower level of consciousness. As communication is difficult in these cases, doctors should keep a high level of awareness about the possibility of the condition developing.

Symptoms

The early symptoms of compartment syndrome are non-specific, which can lead to a delay in diagnosis. Classic features of the condition, which include pain, pallor, paraesthesia, paralysis and pulselessness (also known as the 5 'Ps') all develop later in the course of the condition and are associated with irreversible damage. Symptoms of chronic compartment syndrome tend to develop gradually during exercise and improve with rest.

Symptoms (sourced from the NHS website) can include:

  • cramping pain during exercise, most often in the legs
  • swelling or a visibly bulging muscle
  • a tingling sensation
  • the affected area turning pale and cold
  • in severe cases, difficulty moving the affected body part

Although all these signs have a role in identifying the condition, the overall clinical picture is more important in making a diagnosis than the presence or absence of any one symptom. A diagnosis of compartment syndrome tends to be made over time, following the assessment of the evolving signs and symptoms, rather than in isolation at a single time point. So ongoing review and examinations, ideally performed by the same examiner, are crucial.

Treatment (sourced from NHS website & guidance)

The focus of treatment for compartment syndrome is to relieve the pressure in the affected compartment. Constricting dressings, casts and splints must be removed from the affected area. Surgical intervention is usually required, in the form of a fasciotomy, in which long cuts are made in the fascia layer beneath the skin to release the excess pressure.

Acute compartment syndrome must be treated in hospital using a surgical procedure called an emergency fasciotomy. The doctor or surgeon makes an incision to cut open your skin and fascia surrounding the muscles to immediately relieve the pressure inside the muscle compartment. The wound will usually be closed a few days later. Occasionally, a skin graft may be required to cover the wound.

Chronic compartment syndrome is not usually dangerous and can sometimes be relieved by stopping the exercise that triggers it and switching to a less strenuous activity. Physiotherapy, shoe inserts (orthotics) and non-steroidal anti-inflammatory medicines may assist. Surgery will only be considered if your symptoms persist despite these measures.

Consequences

As well as the serious consequences of a missed diagnosis, an additional aspect of compartment syndrome management involves minimising the risk of a negligence claim in these circumstances. Medical negligence claims arising from compartment syndrome are relatively rare and account for around only 5% of all orthopaedic claims. However, these claims are much more likely to be settled in favour of the patient than other conditions.

Window of opportunity to operate

Cases in which poor communication between doctor, nursing staff and patient has been identified are likely to result in a payment, as are those in which there is a failure to intervene after documentation of an abnormal physical finding. There is also a link between the time between onset of symptoms and performance of fasciotomy and the level of payment secured by the patient. Where fasciotomy was performed within eight hours cases are generally being successfully defended. Therefore, early fasciotomy not only improves the outcome for the patient but also decreases the likelihood of a claim and the level of settlement.

Case Example - ITV News

Back in 2019, a Welsh rugby player, William Rowberry received a stamp to the leg during a rugby match. He continued to play on until the end of the game unaware of what was about to unfold. In the changing room after the game, William's leg began to swell considerably. Four hours later he was on an operating table in the hospital. William underwent two operations and was told by a specialist that he could have lost his leg. William was 26 years old at the time and said that he was told by the doctor that he was very lucky he got there on time. Any longer and the danger was he could have lost his leg.

They had to leave the wound open for 48 hours and then they had to go back in to check if any of the tissue or muscle had died. William was diagnosed with acute compartment syndrome. This real life case highlights the importance of the need to act quickly and the real risks and dangers associated with compartment syndrome.

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