From the Guidelines
Compartment syndrome is a medical emergency that requires immediate attention and often surgical intervention with fasciotomy to prevent irreversible tissue damage and limb loss, as emphasized in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1.
Key Points for Managing Compartment Syndrome
- Recognize the signs: Severe pain out of proportion to the injury, pain with passive stretching, pallor, paresthesia, and pulselessness (the "5 P's") 1.
- Immediate action: Remove any constrictive dressings or casts to help alleviate pressure.
- Surgical intervention: Fasciotomy (surgical decompression) is the definitive treatment and should be performed urgently if compartment syndrome is suspected 1.
- Post-operative care: Monitor for reperfusion injury and manage pain to prevent further complications.
- Prevention: Be vigilant in high-risk situations such as crush injuries, prolonged limb compression, or after vascular procedures.
The diagnosis of compartment syndrome is primarily clinical, relying on a high index of suspicion and rapid action to prevent long-term complications such as contractures, functional impairment, or even limb loss 1. While measurement of compartment pressures can be helpful, it should not delay surgical intervention if clinical signs are present. Prophylactic fasciotomies at the time of revascularization or early in the presentation can avoid a later delay in diagnosis of compartment syndrome and devastating complications associated with this delayed diagnosis 1.
In patients with acute limb ischemia (ALI) who present with prolonged ischemia and dense regional symptoms, concurrent amputation with revascularization can be clinically appropriate, followed by delayed primary closure of the amputation site when the patient is more clinically stable 1. The benefits of prophylactic fasciotomy should be balanced with the knowledge that the procedure is associated with a risk of complications, including dysesthesia related to nerve injury, incisional site complications, and infection 1.
Overall, the management of compartment syndrome requires a multidisciplinary approach, with prompt recognition, immediate intervention, and careful post-operative care to optimize outcomes and prevent long-term morbidity and mortality.
From the Research
Diagnosis of Compartment Syndrome
- The diagnosis of compartment syndrome is largely clinical, with the classical description of 'pain out of proportion to the injury' 2
- Compartment pressure monitors can be a helpful adjunct where the diagnosis is in doubt 2
- Clinical examinations, such as serial examinations, are crucial in diagnosing compartment syndrome, and compartment pressure monitoring may be useful when clinical examinations are compromised 3
- Symptoms of compartment syndrome include numbness, tingling, pain, and coolness to the distal extremity, as well as poor capillary refill and decreased pulse oximetry 4
Treatment of Compartment Syndrome
- Initial treatment involves the removal of any constricting dressings or casts, avoiding hypotension, and optimizing tissue perfusion by keeping the limb at heart level 2
- Definitive treatment is necessary with timely surgical decompression of all the involved compartments if symptoms persist 2
- Surgical intervention, such as fasciotomy, is often the only effective treatment for compartment syndrome, although the best timing of intervention may vary depending on the body region and severity of the condition 5
- Prehospital treatment of extremity injuries that will prevent or limit compartment syndrome includes immobilization, elevation, and cooling 4
Timing of Surgical Intervention
- The timing of surgical intervention for compartment syndrome can be stratified into four categories: immediate, early, delayed, and prophylactic decompression, depending on the severity and location of the condition 5
- Immediate decompression is necessary for compartmental syndromes that can rapidly lead to patient death or extreme disability if left untreated 5
- Early decompression is recommended within 3-12 hours, before clinical signs of irreversible deterioration occur 5