From the Guidelines
The recommended treatment for compartment syndrome is immediate surgical fasciotomy, which involves making incisions to release pressure within the affected compartment, as stated 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. This procedure must be performed urgently, ideally within 6 hours of diagnosis, to prevent permanent tissue damage. The surgeon will make one or more incisions through the skin and fascia covering the affected muscle compartment, leaving the wounds open initially to allow for swelling. Prior to surgery, any constrictive dressings, casts, or splints should be removed. Supportive measures include adequate pain management (often requiring opioid analgesics), maintaining hydration, and monitoring renal function as rhabdomyolysis may develop. Following fasciotomy, wounds are typically left open for 48-72 hours before delayed primary closure or skin grafting. Physical therapy is essential during recovery to restore function. Fasciotomy is necessary because compartment syndrome involves increased pressure within a closed fascial space that compromises circulation and nerve function. Without surgical decompression, the pressure continues to increase, leading to irreversible muscle and nerve damage, tissue necrosis, and potentially limb loss or life-threatening complications. 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, as noted in the 2024 guideline 1. In patients with ALI who present with prolonged ischemia and dense regional symptoms, concurrent amputation with revascularization can be clinically appropriate, as stated in the 2024 guideline 1. The diagnosis of compartment syndrome is based on the history and associated clinical findings, but in certain circumstances, may be confirmed with the measurement of elevated compartment pressures, as mentioned in the 2024 guideline 1. The management of kidney injury built up after rhabdomyolysis has no specificity, and experts refer to the French recommendations for acute kidney injury in the perioperative period and intensive care units 1. Additional risk-factors in developing ACS after lower limb trauma include open fracture, intramedullary nailing, anticoagulation, high energy injury, penetrating trauma, vascular injury, burns, the use of tourniquets, and haemophilia, as noted in the 2021 guideline from the Association of Anaesthetists 1.
Some key points to consider in the treatment of compartment syndrome include:
- Immediate surgical fasciotomy to release pressure within the affected compartment
- Removal of constrictive dressings, casts, or splints prior to surgery
- Supportive measures such as pain management, hydration, and monitoring renal function
- Delayed primary closure or skin grafting after 48-72 hours
- Physical therapy to restore function during recovery
- Prophylactic fasciotomies at the time of revascularization or early in the presentation to avoid delayed diagnosis and complications.
It is essential to prioritize the single most recent and highest quality study, which in this case is the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1. This guideline provides the most up-to-date and evidence-based recommendations for the treatment of compartment syndrome. By following these guidelines and considering the key points mentioned above, healthcare professionals can provide optimal care for patients with compartment syndrome and improve outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Compartment Syndrome Treatment
The recommended treatment for compartment syndrome is primarily surgical, with the goal of relieving pressure and restoring blood flow to the affected area.
- Surgical intervention, specifically fasciotomy, is often the only effective treatment for compartment syndrome, as it allows for the decompression of affected organs or areas of the body 2.
- The timing of surgical intervention can vary depending on the severity and location of the compartment syndrome, with some cases requiring immediate decompression, while others may allow for early or delayed decompression 2.
- Fasciotomy has been shown to be effective in reducing intracompartmental pressure and preventing long-term complications such as permanent dysaesthesia, ischaemic contractures, and muscle dysfunction 3.
- In some cases, fasciotomy may be performed prophylactically in situations where there is a high risk of compartment syndrome developing, such as after arterial vascular trauma of the lower extremity 4.
- The success of fasciotomy in treating compartment syndrome has been demonstrated in various studies, with one study showing that 11 out of 14 patients reported complete resolution of symptoms and return to normal activity levels after undergoing fasciotomy for chronic compartment syndrome in the lower limb 5.
Prehospital Treatment
Before surgical intervention, prehospital treatment of extremity injuries that may lead to compartment syndrome includes:
- Immobilization to prevent further injury and reduce swelling 6.
- Elevation to reduce swelling and promote blood flow 6.
- Cooling to reduce metabolic rate and decrease tissue damage 6.
- Recognition of the symptoms of compartment syndrome, such as numbness, deep pain, and coolness to the distal extremity, is crucial for prompt medical evaluation and treatment 6.
Predictors for Fasciotomy
Certain factors can predict the need for fasciotomy after arterial vascular trauma of the lower extremity, including: