What is the management of compartment syndrome?

Management of Compartment Syndrome

Immediate fasciotomy of all involved compartments is the only effective treatment for diagnosed compartment syndrome and must be performed urgently to prevent irreversible tissue damage, permanent functional impairment, and potentially death. 1, 2, 3

Immediate Emergency Actions

Remove All External Compression

• Immediately remove all constricting dressings, casts, splints, or bandages when compartment syndrome is suspected 1, 4
• This is the most important first step and may prevent progression in early cases 4

Limb Positioning

• Position the limb at heart level (not elevated) to optimize perfusion pressure 1, 2, 3
• Elevation decreases arterial inflow and worsens tissue ischemia 1, 2, 3

Urgent Surgical Consultation

• Arrange immediate surgical consultation for fasciotomy without any delay 1, 2
• Time is critical—irreversible tissue damage occurs within 6 hours of onset 5, 6

Diagnostic Confirmation When Uncertain

When to Measure Compartment Pressures

• Measure compartment pressures if diagnosis remains in doubt, particularly in obtunded, sedated, or uncooperative patients who cannot reliably report pain 1, 2, 3
• Fasciotomy is indicated when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic BP minus compartment pressure) is <30 mmHg 3

Critical Warning: Do Not Wait for Late Signs

• Never wait for the "5 P's" (pulselessness, pallor, paralysis, paresthesia, poikilothermia) as these indicate irreversible tissue damage has already occurred 1, 2, 3
• Pain out of proportion to injury is the earliest and most reliable warning sign 2, 3
• Pain on passive stretch of affected muscles is the most sensitive early clinical sign 2, 3

Definitive Surgical Management

Fasciotomy Technique

• Perform immediate fasciotomy of all involved compartments through long incisions of both skin and fascia 1, 2, 3, 4
• Split all retinacula, evacuate hematomas, and excise any necrotic tissue 4
• Do not close the skin due to postoperative swelling which can cause rebound compartment syndrome 4

Post-Fasciotomy Care

• Monitor for myoglobinuria and maintain urine output >2 mL/kg/h if myoglobinuria develops to prevent acute kidney injury from rhabdomyolysis 1, 2, 3
• Provide diligent wound care to prevent infection and facilitate eventual closure 1, 2, 3
• Consider negative pressure wound therapy to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 1, 2, 3
• Perform delayed wound closure after 4-8 days when edema decreases, using delayed sutures or mesh graft 4
• Monitor for compartment syndrome recurrence, particularly in severe cases 1, 2, 3

Special Considerations: Abdominal Compartment Syndrome

Monitoring and Medical Management

• Measure intra-abdominal pressure (IAP) at least every 4-6 hours when intra-abdominal hypertension (IAP ≥12 mmHg) is present 1
• Titrate therapy to maintain IAP <15 mmHg 1
• Implement stepwise medical management: evacuate intraluminal contents, evacuate intra-abdominal lesions, improve abdominal wall compliance, and optimize fluid administration 1

Surgical Decompression Indications

• Perform decompressive laparotomy when IAP ≥20 mmHg with new organ dysfunction/failure 1
• Decompressive laparotomy is recommended in cases of overt abdominal compartment syndrome compared to strategies without decompression 7
• Consider percutaneous catheter drainage to remove obvious intraperitoneal fluid before proceeding to laparotomy, as this may alleviate the need for surgical decompression 7

Trauma-Specific Recommendations

• Use prophylactic open abdomen in trauma patients undergoing laparotomy who are suffering from physiologic exhaustion versus closure with expectant IAP management 7
• Do not routinely utilize open abdomen for severe intra-peritoneal contamination during emergency laparotomy for intra-abdominal sepsis unless IAH is a specific concern 7

Prophylactic Fasciotomy Indications

High-Risk Scenarios Requiring Prophylaxis

• Consider prophylactic fasciotomy in acute limb ischemia with threatened but salvageable limb (Category IIa or IIb), particularly with prolonged or severe tissue ischemia 1, 3
• Prophylactic fasciotomy is reasonable when time to revascularization exceeds 4 hours in Category IIb ischemia 3
• Prophylactic fasciotomy at time of revascularization prevents delayed diagnosis and associated complications 2, 3

Critical Pitfalls to Avoid

• Never rely solely on palpation for diagnosis—it is unreliable with sensitivity of only 54% and specificity of 76% 1, 2, 3
• Never delay diagnosis in obtunded or sedated patients—measure compartment pressures earlier in these populations 1, 2, 3
• Never miss compartment syndrome in patients without fractures—it can occur with soft tissue injuries alone 1, 2, 3
• Never elevate the limb excessively—this further decreases perfusion pressure and worsens ischemia 1, 2, 3
• Never underestimate relatively minor mechanisms of injury—compartment syndrome can develop from seemingly minor trauma 8