What is the management for compartment syndrome?

Management of Compartment Syndrome

Immediate fasciotomy of all involved compartments is the definitive treatment when compartment syndrome is diagnosed, and this must be performed urgently to prevent irreversible tissue damage within 6 hours. 1, 2

Initial Emergency Management

Immediate Actions (Before Fasciotomy)

• Remove all constricting dressings, casts, or splints immediately when compartment syndrome is suspected 1, 3
• Position the limb at heart level (not elevated, as elevation decreases perfusion pressure and worsens ischemia) 1, 4
• Avoid hypotension and optimize tissue perfusion to maintain adequate compartment blood flow 2
• Arrange urgent surgical consultation for fasciotomy without delay 1, 4

Diagnostic Confirmation When Uncertain

• Measure compartment pressures if diagnosis remains in doubt, particularly in obtunded or uncooperative patients who cannot reliably report pain 1
• Do not wait for late signs (pulselessness, pallor, paralysis) as these indicate irreversible tissue damage has already occurred 1, 4

Definitive Surgical Management

Fasciotomy Technique

• Perform immediate fasciotomy of ALL involved compartments when compartment syndrome is diagnosed 1
• Use long incisions of both skin and fascia to ensure adequate decompression 3
• Split retinacula, evacuate hematomas, and excise necrotic tissue during the procedure 3
• Consider rigid fixation of fractures if present during the same procedure 3

Critical Surgical Principles

• Do NOT close the skin primarily after fasciotomy, as postoperative swelling can produce rebound compartment syndrome 3
• Leave wounds open for 4-8 days until edema decreases 3
• Perform delayed closure with sutures or mesh graft after swelling resolves 3
• Conduct a second-look operation for tissue re-debridement at the time of delayed closure 3

Post-Fasciotomy Management

Wound Care and Monitoring

• Monitor for myoglobinuria and maintain urine output >2 ml/kg/h if myoglobinuria develops 1
• Provide diligent wound care to mitigate complications and facilitate closure 1
• Consider negative pressure wound therapy to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 1
• Monitor for compartment syndrome recurrence, particularly in severe cases 1

Closure Strategies

• 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 as an effective alternative when primary closure is not feasible 1

Special Considerations by Location

Abdominal Compartment Syndrome

For intra-abdominal hypertension (IAP ≥ 12 mmHg): 5

• Measure IAP at least every 4-6 hours or continuously 5
• Titrate therapy to maintain IAP < 15 mmHg 5

Medical management stepwise approach (escalate if no response): 5

• Evacuate intraluminal contents (nasogastric/rectal tubes, prokinetic agents, enemas) 5
• Evacuate intra-abdominal lesions (ultrasound identification, percutaneous catheter drainage) 5
• Improve abdominal wall compliance (adequate sedation/analgesia, remove constrictive dressings, consider neuromuscular blockade) 5
• Optimize fluid administration (avoid excessive resuscitation, aim for zero to negative fluid balance) 5

Surgical decompression indicated when: 5

• IAP ≥ 20 mmHg with new organ dysfunction/failure 5
• Patient's IAH/ACS is refractory to medical management 5

Foot Compartment Syndrome

• Requires decompression of both short pedal muscle compartments AND adequate skin release due to thin soft tissue coverage and diminished blood supply 3

Critical Pitfalls to Avoid

• Never wait for late signs (pallor, pulselessness, paralysis) as these indicate significant irreversible tissue damage 1, 4
• Never rely solely on palpation for diagnosis, as it is unreliable (sensitivity 54%, specificity 76% in children) 1
• Never elevate the limb excessively, as this further decreases perfusion pressure and worsens compartment syndrome 1, 4
• Never delay diagnosis in obtunded patients—measure compartment pressures earlier in these populations 1
• Never close skin primarily after fasciotomy, as this can cause rebound compartment syndrome 3
• Never miss compartment syndrome in patients without fractures, as it can occur with soft tissue injuries alone 1

Timing Classification for Surgical Intervention

• Immediate decompression: For compartment syndromes where missed therapy would rapidly lead to death or extreme disability 6
• Early decompression: Within 3-12 hours and before clinical signs of irreversible deterioration 6
• Prophylactic fasciotomy: Reasonable in acute limb ischemia with threatened but salvageable limb, particularly with prolonged or severe tissue ischemia 1