From the Guidelines
Compartment syndrome should be treated with immediate fasciotomy to decompress the affected compartment, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1.
Diagnosis
Diagnosis of compartment syndrome is primarily clinical, based on the presence of pain out of proportion to the injury, pain with passive stretching, paresthesia, pallor, paralysis, and pulselessness (the "6 Ps"), though pulselessness is often a late finding. Intracompartmental pressure measurement is helpful when the diagnosis is uncertain, with pressures above 30 mmHg or within 30 mmHg of diastolic blood pressure indicating compartment syndrome 1.
Treatment
Treatment consists of immediate fasciotomy to decompress the affected compartment. This surgical procedure involves making incisions through the skin and fascia to relieve pressure and restore blood flow. For acute compartment syndrome, fasciotomy should be performed within 6 hours of onset to prevent irreversible muscle and nerve damage.
- Key points to consider in treatment:
- Fasciotomy is indicated in hypotensive patients with intracompartment pressures ≥ 20 mm Hg, in uncooperative or unconscious patients with intracompartment pressures ≥ 30 mm Hg, or in normotensive patients with positive clinical findings, who have compartment pressures ≥ 30 mmHg, and whose duration of increased pressure is unknown or thought to be longer than 8 h 1.
- The benefits of fasciotomy decrease, and the disadvantages increase considerably the later fasciotomy is performed.
- Amputation should only be performed if lifesaving, e.g., with a clearly unsalvageable limb or rapidly spreading, therapy-resistant sepsis.
Post-Fasciotomy Management
Post-fasciotomy management includes:
- Wound care
- Pain control
- Monitoring for complications such as infection or rhabdomyolysis
- The wounds are typically left open initially and may require delayed primary closure or skin grafting.
Prevention
Prevention of compartment syndrome involves:
- Careful monitoring of at-risk patients (those with fractures, crush injuries, or vascular injuries)
- Avoiding constrictive dressings
- Maintaining appropriate limb positioning Early recognition and surgical intervention are crucial for preserving limb function and preventing long-term disability.
From the Research
Diagnosis of Compartment Syndrome
- Compartment syndrome can occur in many body regions and may range from asymptomatic alterations to severe, life-threatening conditions 2
- Diagnosis is made on the basis of physical examination and repeated intracompartmental pressure (ICP) measures, with ICP higher than 30 mmHg of diastolic blood pressure being significant of compartment syndrome 3
- Symptoms include pain out of proportion and pain with passive stretch of the wrist and digits, particularly in forearm compartment syndrome 4
Treatment of Compartment Syndrome
- Surgical intervention to decompress affected organs or areas of the body is often the only effective treatment, with fasciotomy being the mainstay treatment 2, 3
- Timing of decompression is crucial, with immediate decompression recommended for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, and early decompression (within 3-12 hours) for others 2
- Delayed decompression can lead to irreversible ischemic damage to muscles and peripheral nerves 3
- Closure of fasciotomy wounds can be accomplished by primary closure, but many patients require additional forms of soft tissue coverage procedures 5, 4
Management of Compartment Syndrome
- Multidisciplinary care instituted at the time of fasciotomy can facilitate timely closure and minimize the complication profile 5
- Several approaches are available to enhance outcomes of fasciotomy wounds, including early primary closure, gradual approximation, skin grafting, and negative pressure therapy 5
- Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function 6