From the Guidelines
Compartment syndrome is a surgical emergency that requires prompt diagnosis and treatment to prevent permanent tissue damage, and immediate fasciotomy is the recommended treatment to decompress the affected compartment. The diagnosis of compartment syndrome relies on clinical findings, including pain out of proportion to injury, pain with passive stretching, paresthesia, pallor, paralysis, and pulselessness (the "6 Ps"), though pulselessness is often a late finding 1. Intracompartmental pressure measurement is helpful when clinical assessment is difficult, with pressures >30 mmHg or within 30 mmHg of diastolic pressure indicating compartment syndrome 1.
Clinical Findings and Diagnosis
The clinical signs of compartment syndrome have a low sensitivity for diagnosis but a high negative predictive value 1. The "6 Ps" of compartment syndrome are pain, paresthesia, paresis, pallor, paralysis, and pulselessness, but pulselessness and pallor are often late signs that indicate irreversible damage 1. A high clinical suspicion is necessary to permit early diagnosis of compartment syndrome, especially in patients with severe limb trauma or those at risk of reperfusion injury 1.
Treatment and Management
Treatment consists of immediate fasciotomy to decompress the affected compartment, which involves making incisions through the skin and fascia to relieve pressure 1. The specific approach depends on the affected compartment, with a volar approach and possible dorsal incisions needed for the forearm, and a two-incision technique addressing all four compartments standard for the leg 1. Post-fasciotomy management includes leaving wounds open initially with delayed primary closure or skin grafting after swelling subsides, typically 3-7 days later 1.
Post-Fasciotomy Care
Adequate pain control, elevation of the affected limb, and close neurovascular monitoring are essential, and antibiotics are typically administered perioperatively 1. Physical therapy should begin as soon as appropriate to maintain range of motion and strength, and compartment syndrome represents a surgical emergency, as delayed treatment beyond 6-8 hours can lead to irreversible muscle and nerve damage, resulting in contractures, functional impairment, or even necessitating amputation in severe cases 1. 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.
From the Research
Diagnosis of Compartment Syndrome
- Compartment syndrome is a surgical emergency that can lead to significant morbidity and mortality if not rapidly identified and treated 2
- The diagnosis is largely clinical, with the classical description of 'pain out of proportion to the injury' 3
- Compartment pressure monitors can be a helpful adjunct where the diagnosis is in doubt, with intracompartmental pressures higher than 30 mmHg of diastolic blood pressure being significant of compartment syndrome 4
- Measurement of intracompartmental pressures using a pressure monitor is the most reliable test, though noninvasive means of diagnosis are under study 2
Treatment and Management of Compartment Syndrome
- Treatment involves surgical consultation for emergent fasciotomy, as well as resuscitation and management of complications, such as rhabdomyolysis 2
- Initial treatment is with the removal of any constricting dressings or casts, avoiding hypotension and optimizing tissue perfusion by keeping the limb at heart level 3
- Definitive treatment is necessary with timely surgical decompression of all the involved compartments, which should be performed as early as possible to prevent irreversible ischemic damage to muscles and peripheral nerves 4, 3
- Rehabilitation can reduce complications that occur even in patients who were promptly and properly treated, especially in cases of upper extremity compartment syndrome where patients may lose fine motor function 5
Factors Associated with Compartment Syndrome
- The likelihood and severity of acute compartment syndrome are comparable in the leg and the forearm 6
- Compartment pressure measurement, male sex, and non-vascular mechanism of injury are associated with higher likelihood of acute compartment syndrome or with the use of split-thickness skin graft in patients undergoing fasciotomy 6
- Forearm fasciotomy is associated with poorer muscle appearance and contracture compared with leg fasciotomy 6