What is the management and treatment of a patient with symptoms of compartment syndrome?

Compartment Syndrome: Workup, Diagnosis, and Management

Immediate Emergency Actions

Remove all constricting elements immediately—including dressings, casts, splints, or bandages—and arrange urgent surgical consultation for fasciotomy without delay, as this is the only definitive treatment to prevent irreversible tissue necrosis. 1, 2

• Position the limb at heart level (not elevated), as excessive elevation further decreases perfusion pressure and worsens ischemia 1, 2, 3
• Do not wait for imaging or late signs before acting—time is critical 1, 4

Clinical Diagnosis

Cardinal Presenting Features

Pain out of proportion to the injury is the earliest and most reliable warning sign of compartment syndrome. 2, 3, 5, 4

• Pain with passive stretch of the affected muscle compartment is the most sensitive early sign 2, 3
• Increasing firmness/tension of the compartment occurs as pressure rises 2
• Paresthesias (sensory changes) indicate nerve ischemia 2, 5, 6

Critical Diagnostic Algorithm

The diagnosis is primarily clinical based on pain out of proportion and pain with passive stretch 2. However, clinical signs alone have limitations:

• Severe pain alone provides only 25% positive predictive value for diagnosis 2
• Pain plus pain on passive stretch increases positive predictive value to 68% 2
• Pain, pain on passive stretch, and paralysis together reach 93% positive predictive value—but paralysis indicates irreversible muscle damage has already occurred 2

When to Measure Compartment Pressures

Measure compartment pressures only if diagnosis remains uncertain, particularly in: 1, 2, 3

• Obtunded or sedated patients who cannot report pain
• Confused or uncooperative patients
• Cases with equivocal clinical findings

Use traditional needle manometry, multiparameter monitors, or dedicated transducer-tipped intracompartmental pressure monitors for measurement. 2

Pressure Thresholds for Fasciotomy

• Absolute compartment pressure ≥30 mmHg 2
• Differential pressure (diastolic blood pressure minus compartment pressure) ≤30 mmHg—this is the most recognized cut-off for intervention in current practice 2

High-Risk Populations

Maintain heightened suspicion in: 2

• Young men under 35 years with tibial fractures
• Patients with crush injuries or high-energy trauma
• Patients with vascular injuries or burns
• Patients on anticoagulation
• Motorcyclists with lower-extremity injuries 7

Definitive Surgical Management

Perform immediate fasciotomy of all involved compartments when compartment syndrome is diagnosed—this is the only effective treatment to prevent irreversible tissue damage. 1, 2, 3

Fasciotomy Technique Considerations

• Long incisions of skin and fascia are required 8
• Split all retinacula and evacuate hematomas 8
• Excise necrotic tissues if present 8
• Do not close the skin primarily—postoperative swelling can produce rebound compartment syndrome 8
• Delayed closure at 4-8 days after edema decreases, using delayed sutures or mesh graft 8

Post-Fasciotomy Management

• Monitor for myoglobinuria and maintain urine output >2 ml/kg/h to prevent acute kidney injury from rhabdomyolysis 1, 3
• Consider negative pressure wound therapy to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 1, 2
• Provide diligent wound care to mitigate complications 1, 2
• Monitor for compartment syndrome recurrence, particularly in severe cases 1, 2

Special Anatomic Considerations

Foot Compartment Syndrome

• The foot contains nine compartments that should all be assessed 5
• Decompression requires opening compartments of short pedal muscles and adequate skin release 8
• Special challenges exist due to thin soft tissue coverage and diminished blood supply to foot bones 8

Abdominal Compartment Syndrome

• Measure intra-abdominal pressure at least every 4-6 hours when intra-abdominal hypertension (IAP ≥12 mmHg) is present 1
• Implement stepwise medical management to maintain IAP <15 mmHg 1
• Surgical decompression indicated when IAP ≥20 mmHg with new organ dysfunction or when refractory to medical management 1

Critical Pitfalls to Avoid

Never wait for late signs (pulselessness, pallor, paralysis)—these indicate significant irreversible tissue damage has already occurred. 1, 2, 3

• Never rely solely on palpation for diagnosis—sensitivity is only 54% and specificity 76% in children 1, 2, 3
• Never elevate the limb excessively—this worsens perfusion 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
• Never order imaging studies that delay surgical intervention 2
• Never assume a minor mechanism of injury excludes compartment syndrome 7

Role of Imaging

• Plain X-rays should not be used to rule out compartment syndrome and are frequently normal unless infection and necrosis are advanced 2
• CT has higher sensitivity than plain radiography, showing fat stranding, fluid collections, fascial thickening, and non-enhancing fascia 2
• Ultrasound has no established role in acute compartment syndrome diagnosis 2

Patient Education

All injured patients should be educated to seek immediate care if symptoms of numbness, deep pain, and coolness to the distal extremity occur 7