What are the signs and symptoms of compartment syndrome?

Signs and Symptoms of Compartment Syndrome

The classic signs and symptoms of compartment syndrome include pain out of proportion to the injury, pain on passive stretch of the affected muscle, paresthesia, paresis, and a tense/swollen compartment, with pulselessness and pallor being late signs indicating irreversible damage. 1

Early Signs (Most Important for Timely Diagnosis)

Early recognition of compartment syndrome is critical for preventing permanent tissue damage and preserving limb function. The earliest and most reliable signs include:

• Pain:

  • Pain out of proportion to the injury or clinical situation 1
  • Pain that is unresponsive to appropriate analgesia 2
  • Pain on passive stretching of muscles in the affected compartment (considered one of the most sensitive early signs) 1

• Physical changes in the compartment:

  • Tension or firmness of the affected compartment 1
  • Swelling of the affected area 1

• Sensory changes:

  • Paresthesia (abnormal sensations like tingling, numbness) in the distribution of nerves traversing the compartment 1

Late Signs (Indicate Severe Damage)

These signs appear later and indicate significant vascular compromise and tissue damage:

• Paresis/Paralysis: Weakness or inability to move the affected muscles 1
• Pulselessness: Diminished or absent pulses distal to the affected compartment 1
• Pallor: Pale appearance of the affected limb 1
• Poikilothermia: Cool temperature of the affected limb 1, 3

Diagnostic Value of Clinical Signs

The sensitivity and positive predictive value of individual clinical signs are low, while specificity and negative predictive value are high 1:

• Palpation of the suspected compartment alone has sensitivity of 54% and specificity of 76% 1
• Severe pain alone gives only about 25% chance of correct diagnosis 1
• Combined signs increase diagnostic accuracy:
  • Pain + pain on passive stretch: 68% positive predictive value
  • Pain + pain on passive stretch + paralysis: 93% positive predictive value 1

Monitoring and Measurement

In cases where clinical diagnosis is unclear or in patients who cannot communicate (sedated, unconscious):

• Compartment pressure measurement is indicated 1
• Normal compartment pressure is less than 10 mmHg 1
• Fasciotomy is typically indicated when:
  • Compartment pressure is ≥30 mmHg in normotensive patients with positive clinical findings 1
  • Compartment pressure is within 10-30 mmHg of the diastolic pressure (differential pressure) 1
  • Compartment pressure is ≥20 mmHg in hypotensive patients 1

Risk Factors for Developing Compartment Syndrome

Patients with the following are at higher risk:

• Fractures (especially tibial shaft fractures) 1
• Crush injuries 1
• Hemorrhagic injuries 1
• Reperfusion after ischemia 1
• Hypotension 1
• Young men under 35 years with tibial fractures 1
• High-energy injuries, open fractures, intramedullary nailing 1
• Burns, tourniquet use, vascular injuries 1

Clinical Pitfalls to Avoid

1. Waiting for late signs: Pulselessness and pallor are late signs that indicate irreversible damage has likely occurred 1

2. Relying on a single clinical sign: Individual signs have poor sensitivity; multiple signs increase diagnostic accuracy 1

3. Overlooking compartment syndrome in unconscious or sedated patients: These patients cannot report pain, making diagnosis challenging and requiring a lower threshold for compartment pressure measurement 1

4. Delaying diagnosis: Compartment syndrome is a surgical emergency requiring prompt recognition and treatment to prevent permanent tissue damage 2

5. Tight dressings or casts: These can exacerbate or cause compartment syndrome and should be removed if suspected 1

Regular monitoring (every 30 min to 1 hour) during the first 24 hours is essential in high-risk patients, with particular attention to the early signs of compartment syndrome 1.