What are the steps to manage compartment syndrome progression?

Management of Compartment Syndrome Progression

Immediate fasciotomy is the definitive treatment for compartment syndrome progression to prevent irreversible tissue damage, limb loss, and systemic complications. 1

Diagnosis and Monitoring

• Pain out of proportion to injury is the earliest and most reliable warning sign of acute compartment syndrome 2
• Pain on passive stretch of the affected muscle compartment is considered the most sensitive early sign 2
• Monitor for increasing firmness/tension of the compartment as intracompartmental pressure rises 2
• Paresthesia (sensory changes) indicates nerve ischemia, while paralysis, pulselessness, and pallor are late signs indicating severe tissue damage 2, 3
• Maintain a high index of suspicion in at-risk populations, particularly young men under 35 with tibial fractures, patients with crush injuries, vascular injuries, burns, or those on anticoagulation 2, 4
• Clinical signs alone have limited sensitivity but high specificity for diagnosing compartment syndrome 2, 5
• Measure compartment pressures if diagnosis remains in doubt, particularly in obtunded or uncooperative patients 2, 6

Immediate Management Steps

1. Position the affected limb at heart level (not elevated) when compartment syndrome is suspected 2
2. Remove any constricting dressings or casts to prevent further pressure increases 7
3. Avoid hypotension and optimize tissue perfusion 7
4. Arrange urgent surgical consultation for fasciotomy when compartment syndrome is diagnosed 2, 3
5. Monitor for myoglobinuria and maintain urine output >2 ml/kg/h if myoglobinuria develops 1

Surgical Management

• Perform immediate fasciotomy of all involved compartments when compartment syndrome is diagnosed 1, 3
• In patients with acute limb ischemia (ALI) with a threatened but salvageable limb (category IIa or IIb), prophylactic fasciotomy is reasonable based on clinical findings 1
• For patients with prolonged or severe tissue ischemia, fasciotomy is indicated to mitigate reperfusion syndrome 1
• Prophylactic fasciotomies at the time of revascularization can prevent delayed diagnosis of compartment syndrome and associated complications (tissue necrosis, infection, limb amputation) 1

Post-Fasciotomy Management

• If minimal tissue bulge is noted after fasciotomy or resolves with systemic diuresis and leg elevation, consider early delayed primary closure 1
• For patients in whom delayed primary closure is not possible, negative pressure wound therapy (NPWT) is effective to reduce discomfort and facilitate closure 1
• Provide diligent wound care to mitigate complications and facilitate closure 1
• Monitor for compartment syndrome recurrence, particularly in severe cases 1

Special Considerations

• In patients with ALI and prolonged ischemia undergoing revascularization, concurrent and early amputation may be beneficial to avoid reperfusion morbidity in select cases 1
• For abdominal compartment syndrome, measure intra-abdominal pressure intraoperatively and consider open abdomen management in unstable patients to prevent abdominal compartment syndrome 1
• Avoid common pitfalls such as waiting for late signs of compartment syndrome, relying solely on palpation for diagnosis, or elevating the limb excessively 2, 3

Complications to Monitor

• Tissue necrosis and permanent functional impairment 4
• Rhabdomyolysis and potential renal failure 3
• Disseminated intravascular coagulopathy 1
• Infection of fasciotomy wounds 1
• Nerve injury resulting in dysesthesia 1

By following this algorithmic approach to compartment syndrome management with prompt recognition and surgical intervention, clinicians can significantly reduce morbidity and mortality associated with this limb-threatening and potentially life-threatening condition.