Symptoms of Compartment Syndrome
Pain out of proportion to the injury is the earliest and most reliable warning sign of acute compartment syndrome and should prompt immediate evaluation. 1
Early Clinical Signs (Most Important for Diagnosis)
The following symptoms appear early and are critical for timely diagnosis:
Severe, disproportionate pain: Pain that seems excessive relative to the apparent injury is the cardinal early symptom, though in isolation it only provides approximately 25% diagnostic accuracy 2, 1
Pain on passive stretch: When muscles in the affected compartment are passively stretched, this causes significant pain and is considered by many to be the most sensitive early sign 2, 1
Increasing compartment firmness: The affected area becomes progressively tighter and more tense to palpation as intracompartmental pressure rises 2
Paresthesias: Numbness, tingling, or other sensory changes occur due to nerve ischemia within the compartment 1, 3
Diagnostic Combinations That Increase Accuracy
The presence of multiple symptoms significantly improves diagnostic accuracy:
Severe pain plus pain on passive stretch together provide 68% positive predictive value 2
Pain, pain on passive stretch, and paralysis together provide 93% positive predictive value, though by this stage irreversible muscle damage may have already occurred 2
Late Signs (Indicate Severe Tissue Damage)
These symptoms indicate significant disruption to limb vascularity and viability—diagnosis should be made before these appear: 2
Paralysis: Motor deficits indicating advanced nerve and muscle damage 2, 1
Poikilothermia: Decreased temperature/coolness of the affected limb 2, 3
Critical Pitfalls to Avoid
Do not wait for the "5 P's": Waiting for pulselessness, pallor, paralysis, paresthesias, and poikilothermia means waiting for irreversible tissue damage 2, 1
Do not rely on palpation alone: Compartment palpation has only 54% sensitivity and 76% specificity in children and is unreliable in isolation 2
Do not dismiss minor mechanisms of injury: Compartment syndrome can occur even with seemingly minor trauma 3
Recognize diagnostic difficulty in obtunded patients: Clinical signs may be impossible to elicit in confused, uncooperative, or sedated patients, requiring direct compartment pressure measurement 2