What are the diagnostic criteria and treatment for compartment syndrome?

From the Guidelines

Compartment syndrome is diagnosed through clinical assessment and pressure measurements, requiring prompt surgical intervention when confirmed, with the most recent and highest quality study 1 emphasizing the importance of early recognition and treatment. The diagnostic criteria for compartment syndrome include the classic signs 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.

• The presence of both severe pain and pain on passive stretch of the affected muscle compartment gives a positive predictive value of 68% 1.
• A predictive value of 93% is found if pain, pain on passive stretch and paralysis are present 1. Definitive diagnosis involves measuring compartment pressures, with absolute pressures above 30-45 mmHg or delta pressures (diastolic blood pressure minus compartment pressure) less than 30 mmHg indicating compartment syndrome.
• The use of scoring charts, such as that provided by the UK’s Royal College of Nursing, is recommended to help maintain a heightened sense of awareness of this condition among healthcare workers caring for at-risk patients 1. The gold standard treatment is an emergency fasciotomy, which involves surgical decompression of the affected compartment through incisions that release the fascia.
• This procedure must be performed within 6-8 hours of onset to prevent irreversible muscle and nerve damage 1. Post-fasciotomy care includes wound management with either delayed primary closure or skin grafting after the swelling subsides, typically 3-7 days later.
• Supportive measures include limb elevation, removal of constrictive dressings or casts, maintaining normal blood pressure, and pain management 1. Early recognition and treatment are critical as delayed intervention can lead to permanent disability, muscle necrosis, contractures, infection, and even limb amputation in severe cases.
• 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

Diagnostic Criteria for 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
• Intracompartamental pressure (ICP) higher than 30 mmHg of diastolic blood pressure is significant of compartment syndrome 3
• The 7 clinical signs and symptoms associated with acute compartment syndrome (ACS) of the leg are: pain, paresthesia, paralysis, pallor, poikilothermia, pulselessness, and pressure on palpation (7P's) 4
• However, using any single P to assess for ACS yields a poor prediction, and increasing the number of Ps improves the performance up to 4Ps, regardless of the composition of the combination 4

Treatment for Compartment Syndrome

• 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 2
• If symptoms persist, definitive treatment is necessary with timely surgical decompression of all the involved compartments 2
• Fasciotomy to release the affected compartment should be performed as early as possible because delayed decompression would lead to irreversible ischemic damage to muscles and peripheral nerves 3
• Rehabilitation can reduce complications that occur even in patients who were promptly and properly treated 5

Key Considerations

• Acute compartment syndrome (ACS) is a surgical emergency warranting prompt evaluation and treatment 2, 3
• Resultant ischemic damage may be irreversible within six hours and can result in long-term morbidity and even death 2
• The reliance on the Ps classically taught in medical school does not seem to be sufficient for accurate diagnosis, and objective measures such as continuous pressure or a physiologic marker of ischemia may be better indications for compartment syndrome 4