What are the next steps in managing suspected compartment syndrome of the lower extremities?

Diagnosis and Management of Compartment Syndrome of the Lower Extremities

Patients with suspected compartment syndrome of the lower extremities should be emergently evaluated by a clinician with sufficient experience to assess limb viability, and immediate fasciotomy of all involved compartments is indicated when compartment syndrome is diagnosed. 1

Clinical Presentation and Diagnosis

Early Signs and Symptoms

• Pain out of proportion to the 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 one of the most sensitive early signs 2
• Increasing firmness/tension of the compartment occurs as intracompartmental pressure rises 2
• Paresthesia (sensory changes) results from nerve ischemia 2

Late Signs (Indicate Significant Tissue Damage)

• Paralysis (motor deficits) is a late sign indicating significant tissue damage 2
• Pulselessness, pallor, and decreased temperature are also late signs indicating severe tissue damage 2

Diagnostic Approach

• Initial clinical evaluation should rapidly assess limb viability and potential for salvage without requiring imaging 1
• Clinical signs alone have limitations: low sensitivity but high specificity for diagnosing compartment syndrome 2
• When pain, pain on passive stretch, and paralysis are all present, positive predictive value reaches 93%, but paralysis indicates irreversible muscle damage may have already occurred 2
• Compartment pressure measurement is recommended when diagnosis remains in doubt, particularly in obtunded or uncooperative patients 2
• A high clinical suspicion is necessary to permit early diagnosis 1

Management Algorithm

Immediate Actions

1. Position the limb at heart level (not elevated) when compartment syndrome is suspected 2
2. Remove any constricting dressings or casts 3
3. Administer systemic anticoagulation with heparin unless contraindicated 1
4. Measure compartment pressures if diagnosis remains in doubt 2
5. Arrange urgent surgical consultation for fasciotomy 2

Definitive Treatment

• Immediate fasciotomy of all involved compartments when compartment syndrome is diagnosed 1, 2
• Prophylactic fasciotomy is reasonable in patients with threatened but salvageable limbs (category IIa or IIb) based on clinical findings 1
• Early fasciotomy (performed within 12 hours of onset) results in normal function in 68% of extremities, compared to only 8% with late fasciotomy 4

Post-Fasciotomy Management

• Consider early delayed primary closure if minimal tissue bulge is noted after fasciotomy or resolves with systemic diuresis and leg elevation 1
• Use negative pressure wound therapy when delayed primary closure is not possible 1, 2
• Provide diligent wound care to mitigate complications and facilitate closure 1
• Monitor for myoglobinuria and maintain urine output >2 ml/kg/h if myoglobinuria develops 2
• Monitor for compartment syndrome recurrence, particularly in severe cases 2

High-Risk Populations

• Young men under 35 years with tibial fractures 1, 2
• Patients with fractures, especially tibial shaft fractures (approximately 4-5% of all tibial fractures result in compartment syndrome) 1, 2
• Patients with crush injuries or high-energy trauma 2
• Patients with vascular injuries or burns 2
• Patients on anticoagulation 2
• Motorcyclists who suffer lower-extremity injuries 5
• Patients with prolonged periods of ischemia and more severe ischemia 1

Important Pitfalls to Avoid

• Waiting for late signs such as pallor, pulselessness, and paralysis can lead to irreversible tissue damage 2, 3
• Relying solely on palpation for diagnosis is unreliable (sensitivity 54%, specificity 76% in children) 2
• Delaying diagnosis in obtunded patients can lead to poor outcomes 2
• Missing compartment syndrome in patients without fractures (can occur with soft tissue injuries alone) 2
• Elevating the limb excessively can further decrease perfusion pressure and worsen compartment syndrome 2
• Delaying fasciotomy beyond 12 hours significantly increases complication rates (54% vs. 4.5% for early fasciotomy) 4

Complications to Monitor

• Disseminated intravascular coagulopathy 2
• Infection of fasciotomy wounds 2
• Nerve injury resulting in dysesthesia 2
• Systemic metabolic toxicity 1
• Permanent functional impairment 3
• Limb loss 6