From the Guidelines
The appropriate workup for a patient suspected of having compartment syndrome begins with a thorough clinical assessment focusing on the 6 P's: pain out of proportion, pressure/tense compartment, paresthesia, paralysis, pallor, and pulselessness, as recommended by the most recent guidelines 1. The clinical assessment should be performed promptly, as early diagnosis is critical to prevent permanent tissue damage, muscle necrosis, and potential limb loss.
- Key components of the clinical assessment include:
- Pain with passive stretch of muscles in the affected compartment
- Evaluation of sensory and motor function
- Measurement of compartment pressure using a pressure monitor or needle manometer inserted into the affected compartment, with pressures above 30 mmHg or within 30 mmHg of diastolic blood pressure indicating compartment syndrome 1
- Laboratory tests should include:
- Creatine kinase to assess for muscle damage
- Renal function tests to monitor for rhabdomyolysis complications
- Imaging studies like X-rays or CT scans may be helpful to identify underlying fractures but cannot diagnose compartment syndrome directly.
- Doppler ultrasound may be used to assess blood flow.
- Urgent surgical consultation should be obtained while the workup is in progress, as fasciotomy is the definitive treatment if compartment syndrome is confirmed 1. The benefits of early diagnosis and treatment should be balanced with the potential risks and complications of fasciotomy, including dysesthesia related to nerve injury, incisional site complications, and infection 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
Compartment Syndrome Workup
The appropriate workup for a patient suspected of having compartment syndrome involves a combination of clinical evaluation and diagnostic tests.
- Clinical evaluation: The diagnosis of compartment syndrome is largely clinical, with the classical description of 'pain out of proportion to the injury' 2.
- Diagnostic tests: Compartment pressure monitors can be a helpful adjunct where the diagnosis is in doubt 2.
Initial Treatment
Initial treatment involves:
- Removal of any constricting dressings or casts
- Avoiding hypotension
- Optimizing tissue perfusion by keeping the limb at heart level 2
Definitive Treatment
If symptoms persist, definitive treatment is necessary with timely surgical decompression of all the involved compartments 2.
High-Risk Patients
Patients with high-risk extremity injuries, such as those with penetrating trauma or arterial injury, should be closely monitored for signs of compartment syndrome 3.
Prophylactic Fasciotomy
In some cases, prophylactic fasciotomy may be considered, such as in patients with prolonged vascular ischemia or reperfusion injury 4.