Compartment Syndrome Overview and Management
Compartment syndrome is a surgical emergency caused by elevated tissue pressure within a closed anatomical space that exceeds perfusion pressure, leading to tissue ischemia—immediate fasciotomy is required to prevent irreversible tissue damage, permanent functional impairment, and potentially death. 1, 2
Pathophysiology
Compartment syndrome occurs when interstitial pressure within a closed osseo-fascial compartment rises above perfusion pressure, compromising blood flow. 3, 4 The tough fascial membrane covering muscle groups limits swelling, which progressively restricts lymphatic drainage, venous outflow, and ultimately arterial inflow. 3 Irreversible ischemic damage can occur within 6 hours if untreated. 4
Types of Compartment Syndrome
Limb compartment syndrome most commonly affects the lower leg (tibial fractures) and forearm, typically following fractures, crush injuries, high-energy trauma, vascular injuries, burns, or penetrating trauma with arterial injury. 1, 5, 6
Abdominal compartment syndrome (ACS) is defined as sustained intra-abdominal pressure (IAP) ≥20 mmHg with new organ dysfunction/failure. 7 It can be primary (originating from abdominopelvic injury/disease), secondary (from conditions outside the abdomen), or recurrent. 7
Clinical Presentation
Early Warning Signs
Pain out of proportion to the injury is the earliest and most reliable warning sign of acute compartment syndrome. 5, 4, 8 However, severe pain alone has only approximately 25% positive predictive value for diagnosis. 5
Pain on passive stretch of the affected muscle compartment is considered by some the most sensitive early sign. 5 When both severe pain and pain on passive stretch are present together, positive predictive value increases to 68%. 5
Increasing firmness/tension of the compartment occurs as intracompartmental pressure rises. 5
Late Signs (Indicate Irreversible Damage)
- Paresthesia (sensory changes from nerve ischemia) 5
- Paralysis (motor deficits)—when all three signs (pain, pain on passive stretch, and paralysis) are present, positive predictive value reaches 93%, but paralysis indicates irreversible muscle ischemia has already occurred 5
- Pulselessness, pallor, decreased temperature (coldness)—these are late signs indicating severe tissue damage 1, 5
Diagnostic Challenges
Clinical signs alone have low sensitivity and positive predictive value but high specificity and negative predictive value. 5 Palpation of the suspected compartment is unreliable in isolation (sensitivity 54%, specificity 76% in children). 1, 5
High-Risk Populations
- Young men under 35 years with tibial fractures 5
- Patients with fractures, especially tibial shaft fractures 5
- Patients with crush injuries or high-energy trauma 5
- Patients with vascular injuries, burns, or penetrating trauma with arterial injury 5, 6
- Patients on anticoagulation 5
- Motorcyclists with lower-extremity injuries 3
Immediate Emergency Management
First Actions (Do Not Delay)
Remove all constricting dressings, casts, splints, or bandages immediately when compartment syndrome is suspected. 1, 2
Position the limb at heart level—elevation decreases arterial inflow and worsens tissue ischemia, while dependent positioning increases venous congestion. 1, 2, 5
Arrange immediate surgical consultation for fasciotomy without any delay. 1, 2
Diagnostic Confirmation When Uncertain
Measure compartment pressures if diagnosis remains in doubt, particularly in obtunded, sedated, or uncooperative patients who cannot reliably report pain. 1, 2, 5 This is especially critical in high-risk populations where clinical examination is unreliable. 1, 5
Fasciotomy is indicated when:
- Compartment pressure exceeds 30 mmHg 2
- Differential pressure (diastolic BP minus compartment pressure) is <30 mmHg 2
Definitive Surgical Management
Perform immediate fasciotomy of all involved compartments through long incisions of both skin and fascia when compartment syndrome is diagnosed. 1, 2, 5 At the time of fasciotomy, thoroughly evaluate the forearm vasculature and search for arterial injury, particularly in penetrating trauma cases. 6
Monitor for myoglobinuria and maintain urine output >2 mL/kg/h if myoglobinuria develops to prevent acute kidney injury from rhabdomyolysis. 1, 2, 5
Prophylactic Fasciotomy Indications
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, 5 Prophylactic fasciotomy is reasonable when time to revascularization exceeds 4 hours in Category IIb ischemia. 2
Post-Fasciotomy Wound Management
Consider early delayed primary closure if minimal tissue bulge is noted after fasciotomy or resolves with systemic diuresis and leg elevation. 5
Use negative pressure wound therapy to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure. 1, 5
Provide diligent wound care to mitigate complications and facilitate closure. 1, 5
Monitor for compartment syndrome recurrence, particularly in severe cases. 1, 5
Abdominal Compartment Syndrome Management
Monitoring
Measure IAP at least every 4-6 hours or continuously when intra-abdominal hypertension (IAP ≥12 mmHg) is present. 1, 2 IAP should be measured via the bladder with maximal instillation volume of 25 mL sterile saline, expressed in mmHg, measured at end-expiration in supine position with transducer zeroed at midaxillary line. 7
Grading of Intra-Abdominal Hypertension
- Grade I: IAP 12-15 mmHg 7
- Grade II: IAP 16-20 mmHg 7
- Grade III: IAP 21-25 mmHg 7
- Grade IV: IAP >25 mmHg 7
Medical Management
Implement stepwise medical management approach, titrating therapy to maintain IAP <15 mmHg: 1
- Evacuate intraluminal contents (nasogastric decompression, rectal tube, prokinetics) 1
- Evacuate intra-abdominal lesions (percutaneous drainage of fluid collections) 1
- Improve abdominal wall compliance (sedation, analgesia, neuromuscular blockade if needed) 1
- Optimize fluid administration (avoid excessive resuscitation, consider diuretics) 1
Surgical Decompression
Perform decompressive laparotomy when IAP ≥20 mmHg with new organ dysfunction/failure, or when IAH/ACS is refractory to medical management. 7, 1, 2 Decompressive laparotomy is indicated if medical treatment has failed after repeated and reliable IAP measurements. 7
The open abdomen is an option for emergency surgery patients with severe peritonitis and severe sepsis/septic shock under these circumstances: 7
- Abbreviated laparotomy due to severe physiological derangement 7
- Need for deferred intestinal anastomosis 7
- Planned second look for intestinal ischemia 7
- Persistent source of peritonitis (failure of source control) 7
- Extensive visceral edema with concern for abdominal compartment syndrome development 7
Critical Pitfalls to Avoid
Never wait for late signs (pallor, pulselessness, paralysis)—these indicate significant irreversible tissue damage has already occurred. 1, 2, 5
Never rely solely on palpation for diagnosis—it is unreliable with sensitivity of only 54% and specificity of 76%. 1, 2, 5
Never delay diagnosis in obtunded, sedated, or uncooperative patients—measure compartment pressures earlier in these populations. 1, 2, 5
Never miss compartment syndrome in patients without fractures—it can occur with soft tissue injuries alone, including penetrating trauma with arterial injury. 1, 2, 5, 6
Never elevate the limb excessively—this further decreases perfusion pressure and worsens ischemia. 1, 2, 5
Never apply or leave constricting casts or splints on injured extremities—this can artificially produce compartment syndrome and cause long-term consequences. 3
Complications
Untreated compartment syndrome leads to tissue necrosis, permanent functional impairment, and in severe cases involving large compartments, renal failure and death. 3 Potential complications of fasciotomy include disseminated intravascular coagulopathy, infection of fasciotomy wounds, and nerve injury resulting in dysesthesia. 5