Treatment of Compartment Syndrome
Immediate surgical fasciotomy is the definitive treatment for compartment syndrome and should be performed urgently to prevent irreversible tissue damage, limb loss, and potential mortality. 1
Diagnosis and Assessment
Diagnosis is primarily clinical with the hallmark sign being "pain out of proportion to the injury"
Key clinical findings include:
- Severe pain (especially on passive stretch)
- Paresthesia (numbness/tingling)
- Paralysis/weakness
- Pallor
- Pulselessness (late sign indicating advanced disease)
Compartment pressure measurement:
- Absolute pressure >30 mmHg, or
- Differential pressure (diastolic BP minus compartment pressure) <30 mmHg 1
Treatment Algorithm
1. Immediate Management
- Remove any constrictive dressings, casts, or splints
- Position the affected limb at heart level (avoid elevation)
- Avoid hypotension to maintain tissue perfusion
- Measure compartment pressures if diagnosis is uncertain 1, 2
2. Definitive Treatment
- Surgical fasciotomy of all involved compartments 3, 1
- Must be performed within 6 hours of onset to prevent irreversible tissue damage
- Effectiveness decreases significantly when performed after 8 hours of increased pressure 1
3. Surgical Approach
- For lower extremity:
- Two-incision technique (medial and lateral) to decompress all four compartments
- Anterior, lateral, superficial posterior, and deep posterior compartments must all be released 1
- For upper extremity:
- Volar approach for forearm compartments
- Dorsal approach may be needed for hand compartments 1
4. Wound Management
- Leave fasciotomy wounds open initially
- Negative pressure wound therapy (NPWT) is recommended as first-line therapy for fasciotomy wounds 1
- Delayed primary closure typically after 48-72 hours when swelling subsides
- Consider subcuticular prolene suture technique for delayed primary closure to avoid skin grafting 4
5. Post-Fasciotomy Care
- Monitor for reperfusion syndrome
- Aggressive fluid resuscitation to maintain urine output >2 ml/kg/hr
- Consider sodium bicarbonate to alkalinize urine if myoglobinuria is present 1
- Early physical therapy for range of motion and strengthening 5
Special Considerations
Prophylactic Fasciotomy
- Consider prophylactic fasciotomy in:
Compartment Syndrome After Revascularization
- Patients with acute limb ischemia should be closely monitored and treated for compartment syndrome after revascularization 3
- Fasciotomy should be considered for patients with Category IIb ischemia when time to revascularization is >4 hours 3
Complications of Untreated Compartment Syndrome
- Tissue necrosis
- Permanent functional impairment
- Contractures and deformity
- Weakness and paralysis
- Sensory neuropathy
- Chronic pain
- Renal failure from myoglobinuria
- Death in severe cases 1, 6
Rehabilitation
- Early physical therapy to maintain range of motion
- Progressive strengthening exercises
- Edema management
- Scar management
- Wound care 1, 5
Common Pitfalls to Avoid
- Delaying fasciotomy beyond 6 hours of symptom onset
- Relying on pulselessness as an early sign (it's a late finding)
- Incomplete fasciotomy (not releasing all compartments)
- Elevating the limb (can decrease perfusion pressure)
- Inadequate post-fasciotomy monitoring for reperfusion injury
- Failure to recognize compartment syndrome in sedated or unconscious patients 1, 2