From the Guidelines
Compartment syndrome is a medical emergency that requires immediate fasciotomy to prevent irreversible tissue damage and functional impairment, especially in patients with acute limb ischemia (ALI) who are at risk of reperfusion injury 1.
Diagnosis and Treatment
The diagnosis of compartment syndrome is based on high clinical suspicion, symptoms such as pain out of proportion to injury, pain on passive stretch, paresthesia, pallor, paralysis, and pulselessness, as well as elevated serum creatine kinase levels 1.
- Compartment pressure measurements above 30 mmHg or within 30 mmHg of diastolic pressure can confirm the diagnosis.
- Treatment requires immediate fasciotomy to decompress the affected compartment, as delays beyond 6-8 hours can lead to permanent muscle and nerve damage, contractures, or even necessitate amputation 1.
- Post-fasciotomy, wounds are typically left open initially and closed secondarily after swelling subsides.
Prevention and Monitoring
Prevention involves early recognition in high-risk situations, avoiding constrictive dressings, and careful monitoring of limbs in casts 1.
- Patients with ALI should be monitored and treated for compartment syndrome with fasciotomy after revascularization to prevent the sequelae of reperfusion injury and need for amputation 1.
- In patients with ALI and prolonged ischemia, concurrent and early amputation can be beneficial to avoid the morbidity of reperfusion 1.
Key Recommendations
- Immediate fasciotomy is indicated for patients with clinical evidence of compartment syndrome, and prompt action to measure compartment pressures and perform fasciotomy of all involved compartments is an effective approach 1.
- Prophylactic fasciotomy is reasonable in patients with ALI with a threatened but salvageable limb (category IIa or IIb) based on clinical findings 1.
From the Research
Definition and Causes of Compartment Syndromes
- Compartment syndrome is a limb-threatening and occasionally life-threatening injury that occurs when tissue pressure within a closed anatomic space is greater than the perfusion pressure 2.
- It can occur within any muscle group located in a compartment, most commonly following a severe injury such as a crushing or twisting injury, or mechanisms of injury that involve circumferential burns, ischemia, and tourniquets 2, 3.
- Compartment syndrome can also be caused by artificial means, such as placing a cast or splint around a damaged extremity, compressing it 2.
Symptoms and Diagnosis of Compartment Syndromes
- The first compromised function within the compartment is the flow of lymph and venous blood, followed by numbness, tingling, and pain associated with compartment syndrome 2.
- Symptoms of compartment syndrome include pain out of proportion to the injury, paresthesias, pain with passive stretch, tenseness or firmness of the compartment, focal motor or sensory deficits, or decreased pulse or capillary refill time 4, 5.
- Diagnosis is largely clinical, with the classical description of 'pain out of proportion to the injury', and can be aided by compartment pressure monitors 3, 5.
- Measurement of intracompartmental pressures using a pressure monitor is the most reliable test, although noninvasive means of diagnosis are under study 4.
Treatment and Management of Compartment Syndromes
- Treatment involves surgical consultation for emergent fasciotomy, as well as resuscitation and management of complications, such as rhabdomyolysis 4.
- Immediate surgical fasciotomy is important to prevent severe sequelae of compartment syndrome, but there is controversy about the right time to perform fasciotomy to avoid irreversible ischemic changes 6.
- Prehospital treatment of extremity injuries that will prevent or limit compartment syndrome is immobilization, elevation, and cooling 2.
- Recognition of the syndrome requires emergency personnel to remove the patient to an appropriate emergency department, and patients should be educated to seek care if symptoms of numbness, deep pain, and coolness to the distal extremity occur 2.