What is the treatment for compartment syndrome?

Treatment of Compartment Syndrome

Immediate fasciotomy is the definitive treatment for compartment syndrome and should be performed as soon as the diagnosis is established to prevent irreversible tissue damage and limb loss. 1, 2

Diagnosis and Assessment

Clinical Evaluation

• Pain out of proportion to injury (earliest and most sensitive sign)
• Pain on passive stretch of affected muscle compartment
• Paresthesia (numbness/tingling) in affected nerve distribution
• Tension/firmness of the compartment on palpation
• Late signs (indicating irreversible damage):
  • Paralysis
  • Pallor
  • Pulselessness

Diagnostic Support

• Compartment pressure measurements: Fasciotomy indicated when:
  • Absolute pressure >30 mmHg, or
  • Differential pressure (diastolic BP minus compartment pressure) <30 mmHg 1
• Monitor laboratory values:
  • Creatine kinase (CK) levels
  • Myoglobin
  • Potassium (for rhabdomyolysis) 2

Management Algorithm

1. Immediate Interventions

• Remove all constricting dressings, casts, or splints
• Position limb at heart level (avoid elevation which decreases arterial perfusion)
• Maintain normotension (avoid hypotension which worsens tissue perfusion) 3
• Provide adequate analgesia (but recognize that pain out of proportion despite analgesia is a key diagnostic sign)

2. Definitive Treatment

• Surgical fasciotomy of all involved compartments 2, 1
  • Must be performed within 6 hours of onset to prevent irreversible muscle and nerve damage
  • After 8 hours, damage is typically irreversible 4
  • Do not delay for imaging if clinical diagnosis is clear 1

3. Post-Fasciotomy Management

• Monitor for reperfusion syndrome
• Aggressive fluid resuscitation to maintain urine output >2 ml/kg/hr 2
• Consider sodium bicarbonate to alkalinize urine if myoglobinuria present
• Monitor for development of acute kidney injury
• Wound care with negative pressure wound therapy may be beneficial 2
• Plan for delayed primary closure or skin grafting as appropriate

Special Considerations

Compartment Syndrome After Revascularization

• High risk after acute limb ischemia (ALI) treatment
• Prophylactic fasciotomy is reasonable in patients with:
  • Prolonged ischemia time
  • Category IIa or IIb threatened limbs
  • Clinical evidence of severe tissue ischemia 2

Abdominal Compartment Syndrome

• Treatment involves decompressive laparotomy when medical management fails
• Consider temporary abdominal closure techniques
• Monitor intra-abdominal pressure in high-risk patients 2

Rehabilitation After Fasciotomy

• Early physical therapy to maintain range of motion
• Progressive strengthening exercises
• Edema management
• Scar management and wound care
• Functional rehabilitation to restore limb function 5

Critical Time Factors

• Muscles tolerate 4 hours of ischemia well
• At 6 hours, outcome becomes uncertain
• After 8 hours, damage is typically irreversible 4

Complications of Untreated Compartment Syndrome

• Permanent muscle necrosis and contractures
• Nerve damage and sensory deficits
• Limb dysfunction or loss
• Rhabdomyolysis leading to acute kidney injury
• Systemic inflammatory response
• Death in severe cases 6, 7

Remember that compartment syndrome is a surgical emergency, and the window for intervention is narrow. Clinical suspicion should prompt immediate surgical consultation, as delays in treatment significantly worsen outcomes.