What is the management of compartment syndrome?

Management of Compartment Syndrome

Immediate surgical fasciotomy is the definitive treatment for compartment syndrome and should be performed as soon as the diagnosis is made to prevent tissue necrosis, permanent functional impairment, and potential mortality.

Definition and Pathophysiology

Compartment syndrome occurs when increased pressure within a closed anatomic space exceeds perfusion pressure, leading to tissue ischemia. It develops through two potential mechanisms:

• Arteriovenous gradient hypothesis: Increasing pressure reduces capillary and venous blood flow, causing tissue ischemia, edema, and release of vasoactive mediators, further increasing compartment pressure 1
• Ischemic-reperfusion mechanism: Free radicals, calcium, and vasoactive substrates released under ischemic conditions increase vessel permeability, leading to increased extravascular fluid and pressure 1

Clinical Presentation and Diagnosis

Early recognition is critical for preventing permanent tissue damage. Key clinical findings include:

• Pain: Out of proportion to the injury, often the earliest sign 1, 2
• Pain with passive stretch: Considered one of the most sensitive early signs 1
• Paresthesia: Numbness and tingling in the affected area 1, 2
• Palpable tension: Swelling and firmness of the compartment 1, 2
• Paralysis: Motor deficits (late sign) 1
• Pallor and pulselessness: Late signs indicating significant vascular compromise 1

Note: Clinical signs alone have low sensitivity but high specificity. Pain is typically the earliest finding, while paralysis, pallor, and pulselessness are late signs indicating significant damage has already occurred 1, 2.

Diagnostic Approach

1. Clinical assessment: Evaluate for the 6 P's (pain, paraesthesia, pallor, pulselessness, paralysis, poikilothermia/cold)
2. Compartment pressure measurement: Most reliable test when clinical diagnosis is unclear 1, 2
   • Absolute pressure >30 mmHg or
   • Delta pressure (diastolic BP - compartment pressure) <30 mmHg indicates compartment syndrome

Management Algorithm

1. Immediate Actions

• Remove all restrictive dressings, casts, or splints 3
• Position the limb at heart level (not elevated) to maximize perfusion 3
• Avoid hypotension to maintain adequate perfusion pressure 1
• Urgent surgical consultation for potential fasciotomy 2

2. Definitive Treatment

• Surgical fasciotomy: The definitive treatment for established compartment syndrome 1
  • Must be performed as soon as diagnosis is made
  • All involved compartments must be decompressed
  • Timing is critical - delay leads to irreversible tissue damage

3. Special Considerations by Etiology

Acute Limb Ischemia (ALI)

• Monitor for reperfusion syndrome after revascularization 1
• Perform fasciotomy after revascularization to prevent reperfusion injury 1
• Consider prophylactic fasciotomy in threatened but salvageable limbs (category IIa or IIb) 1
• Consider concurrent amputation with revascularization in cases of prolonged ischemia 1

Abdominal Compartment Syndrome

• Decompressive laparotomy is recommended for overt abdominal compartment syndrome 1
• Consider percutaneous catheter drainage (PCD) for intraperitoneal fluid when technically possible 1

Timing of Intervention

Timing of surgical decompression is critical and should be stratified based on severity 4:

1. Immediate decompression (within minutes to hours): For life-threatening compartment syndromes
2. Early decompression (within 3-12 hours): Before irreversible tissue damage occurs
3. Delayed decompression (after 12 hours): May be considered when signs of clinical deterioration have already occurred
4. Prophylactic decompression: In high-risk situations (e.g., after revascularization for acute limb ischemia)

Complications of Delayed Treatment

Failure to promptly diagnose and treat compartment syndrome can lead to:

• Muscle and nerve necrosis
• Permanent functional impairment
• Contractures
• Need for amputation
• Systemic complications including renal failure from rhabdomyolysis
• Death in severe cases 3, 5, 2

Prevention Strategies

• Careful monitoring of high-risk patients (fractures, crush injuries, vascular injuries)
• Avoid constrictive dressings or casts
• Early recognition and treatment of vascular injuries 6
• Consider prophylactic fasciotomy in high-risk scenarios 1

Key Pitfalls to Avoid

1. Relying solely on clinical signs: History and physical examination alone are often unreliable 1, 2
2. Waiting for late signs (pulselessness, paralysis): By this time, irreversible damage has occurred 1
3. Delaying surgical consultation: Time is critical; earlier fasciotomy leads to better outcomes 5, 2
4. Inadequate fasciotomy: All involved compartments must be fully decompressed 2
5. Overlooking arterial injuries: Penetrating trauma with arterial injury can cause compartment syndrome 6

Remember that compartment syndrome is a surgical emergency requiring prompt recognition and treatment to prevent devastating long-term consequences.