What is the management of suspected compartment syndrome?

Management of Suspected Compartment Syndrome

Suspected compartment syndrome requires immediate fasciotomy after revascularization to prevent reperfusion injury, tissue necrosis, and limb loss. 1

Diagnosis

Early recognition is critical as compartment syndrome can lead to irreversible damage within 6 hours. Diagnosis is based on:

• Clinical signs:

  • Pain out of proportion to injury (earliest and most reliable sign)
  • Pain on passive stretch
  • Paresthesia/sensory deficits
  • Paralysis/motor deficits
  • Pulselessness (late sign indicating advanced disease) 2

• Objective measurement:

  • Compartment pressure >30 mmHg, or
  • Differential pressure (diastolic BP minus compartment pressure) <30 mmHg 2

Management Algorithm

1. Immediate actions:

   • Remove any constricting dressings or casts
   • Position limb at heart level (avoid elevation)
   • Maintain adequate blood pressure to optimize tissue perfusion 3
   • Aggressive fluid resuscitation to maintain urine output >2 ml/kg/hr 2

2. Definitive treatment:

   • Surgical fasciotomy is the definitive treatment when:
     • Clear clinical signs are present
     • Compartment pressure exceeds 30 mmHg
     • Differential pressure is less than 30 mmHg 2

3. Prophylactic fasciotomy is reasonable in:

   • Patients with ALI with threatened but salvageable limbs (category IIa or IIb) 1
   • Cases with prolonged ischemia time 1
   • High-energy injuries with high risk of developing compartment syndrome 1

4. Post-fasciotomy care:

   • Apply negative pressure wound therapy for fasciotomy wounds 2
   • Monitor for reperfusion syndrome
   • Consider sodium bicarbonate for myoglobinuria 2
   • Early physical therapy for range of motion and strength 2

High-Risk Scenarios

Be vigilant for compartment syndrome in patients with:

• Fractures
• Crush injuries
• Hemorrhagic injuries
• Reperfusion after ischemia
• Hypotension 2
• Motorcyclists with lower extremity injuries 4

Military/High-Energy Trauma Considerations

The UK Defence Medical Services approach includes early fasciotomies as part of initial management for casualties with either clinical suspicion or high risk of developing compartment syndrome 1. This approach recognizes that the risks of not performing fasciotomy (limb loss) outweigh the risks of the procedure (hemorrhage, nerve damage, infection, difficult wound closure) 1.

Complications of Untreated Compartment Syndrome

Failure to diagnose and treat compartment syndrome can lead to:

• Tissue necrosis
• Permanent functional impairment
• Contractures and deformity
• Weakness and paralysis
• Sensory neuropathy
• Chronic pain
• Need for multiple rehabilitation procedures
• In severe cases: renal failure and death 2, 4

Pitfalls to Avoid

• Delayed diagnosis: Benefits of fasciotomy decrease significantly when performed after 8 hours of increased compartment pressure 2
• Relying solely on clinical signs: History and physical examination alone are unreliable and cannot rule out the diagnosis 5
• Waiting for all classic signs: By the time all signs are present, irreversible damage may have occurred
• Overlooking compartment syndrome in obtunded patients or children: Diagnosis is particularly difficult in these populations 6
• Placing tight casts/splints: These can create or worsen compartment syndrome 4

Remember that compartment syndrome is a surgical emergency requiring prompt evaluation and treatment, with irreversible damage possible within six hours of onset 3.