Management of Compartment Syndrome
Immediate fasciotomy of all involved compartments is the definitive treatment for compartment syndrome and must be performed urgently to prevent irreversible tissue damage. 1, 2
Immediate Emergency Actions
When compartment syndrome is suspected, take these critical first steps:
- Remove all constricting dressings, casts, splints, or bandages immediately to eliminate external compression 1, 2
- Position the limb at heart level (not elevated) to optimize perfusion pressure—elevation decreases arterial inflow and worsens tissue ischemia 1, 2
- Arrange immediate surgical consultation for fasciotomy without any delay 1, 2
- Do not wait for late signs (pulselessness, pallor, paralysis) as these indicate irreversible tissue damage has already occurred 1, 3
Diagnostic Confirmation When Uncertain
If the diagnosis remains in doubt after initial clinical assessment:
- Measure compartment pressures 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 2
- Never rely solely on palpation for diagnosis—it is unreliable with sensitivity of only 54% and specificity of 76% 2, 3
Definitive Surgical Management
Once compartment syndrome is diagnosed:
- Perform immediate fasciotomy of all involved compartments through long incisions of both skin and fascia 1, 2, 3
- Do not close the skin initially due to postoperative swelling, which can produce rebound compartment syndrome 4
- Monitor for myoglobinuria and maintain urine output >2 mL/kg/h if myoglobinuria develops to prevent acute kidney injury from rhabdomyolysis 1, 2, 3
- Perform delayed closure after 4-8 days when edema decreases, using delayed sutures or mesh graft 4
Post-Fasciotomy Wound Management
After surgical decompression:
- Consider early delayed primary closure if minimal tissue bulge is noted after fasciotomy or resolves with systemic diuresis and leg elevation 3
- Use negative pressure wound therapy to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 1, 3
- Provide diligent wound care to mitigate complications and facilitate closure 1, 3
- Monitor for compartment syndrome recurrence, particularly in severe cases 1, 3
Prophylactic Fasciotomy Indications
In specific high-risk scenarios:
- Consider prophylactic fasciotomy in acute limb ischemia with threatened but salvageable limb (Category IIa or IIb), particularly with prolonged or severe tissue ischemia 1, 2, 3
- Prophylactic fasciotomy is reasonable when time to revascularization exceeds 4 hours in Category IIb ischemia 2
Special Considerations: Abdominal Compartment Syndrome
For intra-abdominal compartment syndrome:
- Measure intra-abdominal pressure (IAP) at least every 4-6 hours when intra-abdominal hypertension (IAP ≥12 mmHg) is present 1, 2
- Implement stepwise medical management including evacuating intraluminal contents, evacuating intra-abdominal lesions, improving abdominal wall compliance, and optimizing fluid administration 1
- Perform decompressive laparotomy when IAP ≥20 mmHg with new organ dysfunction/failure 1, 2
- Surgical decompression is indicated when the patient's intra-abdominal hypertension/abdominal compartment syndrome is refractory to medical management 1
Critical Pitfalls to Avoid
These common errors can lead to devastating outcomes:
- Never wait for late signs (pallor, pulselessness, paralysis) as these indicate significant irreversible tissue damage 1, 2, 3
- Never elevate the limb excessively—this further decreases perfusion pressure and worsens ischemia 1, 2, 3
- Never delay diagnosis in obtunded 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 rely solely on clinical signs as they have low sensitivity and positive predictive value for diagnosis 3