What is the diagnosis and treatment for compartment syndrome?

From the Guidelines

Compartment syndrome is a medical emergency that requires immediate attention, and surgical intervention through fasciotomy is indicated within 6 hours of onset to prevent irreversible damage, as supported by the most recent guidelines 1.

Key Points

• Compartment syndrome occurs when pressure within a muscle compartment increases, restricting blood flow and potentially causing permanent tissue damage.
• The classic symptoms include pain out of proportion to the injury, pain with passive stretching of muscles, paresthesia, pallor, paralysis, and pulselessness (the "6 Ps"), though pulselessness is often a late finding.
• Diagnosis is primarily clinical but can be confirmed by measuring compartment pressures, with values above 30 mmHg or within 30 mmHg of diastolic pressure indicating the need for fasciotomy.
• The urgency of treatment stems from the fact that muscle and nerve tissue can only survive 4-6 hours of ischemia before permanent damage occurs, making this a true surgical emergency.
• After surgical decompression, patients require close monitoring for infection, neurovascular status, and may need physical therapy for rehabilitation.

Management

• Fasciotomy is indicated in patients with clinical evidence of compartment syndrome, and prompt action to measure compartment pressures and to perform fasciotomy of all involved compartments is an effective approach 1.
• In patients with acute limb ischemia (ALI), monitoring for compartment syndrome is an important component of care, and fasciotomy is indicated to mitigate the sequelae of reperfusion syndrome 1.
• The management of kidney injury built up after rhabdomyolysis has no specificity, and experts refer to the French recommendations for acute kidney injury in the perioperative period and intensive care units 1.

Prognosis

• The prognosis of compartment syndrome depends on the promptness of treatment, and delayed treatment can result in permanent damage and increased morbidity and mortality.
• Early fasciotomy can reduce the morbidity and mortality associated with compartment syndrome, and it is essential to raise awareness among healthcare professionals about the importance of early diagnosis and treatment 1.

From the Research

Definition and Causes of Compartment Syndrome

• Compartment syndrome is a limb-threatening and occasionally life-threatening injury that occurs when tissue pressure within a closed anatomic space is greater than the perfusion pressure 2.
• It can occur within any muscle group located in a compartment, and is most common following an event that severely damages a muscle, such as a crushing or twisting injury 2.
• Mechanisms of injury that involve circumferential burns, ischemia, and tourniquets can also cause compartment syndrome 2.

Symptoms and Diagnosis

• The first compromised function within the compartment is the flow of lymph and venous blood, followed by numbness, tingling, and pain associated with compartment syndrome 2.
• The diagnosis is largely clinical, with the classical description of 'pain out of proportion to the injury' 3.
• Compartment pressure monitors can be a helpful adjunct where the diagnosis is in doubt 3.

Treatment and Management

• Initial treatment is with the removal of any constricting dressings or casts, avoiding hypotension, and optimizing tissue perfusion by keeping the limb at heart level 3.
• Definitive treatment is necessary with timely surgical decompression of all the involved compartments 3.
• Hyperbaric oxygen therapy has been shown to be a useful intervention in the management of compartment syndrome, reducing edema and improving tissue viability 4.
• The use of vacuum-assisted closure and hyperbaric oxygen therapy can also accelerate the reduction of edema and permit earlier closure of fasciotomy wounds 5.

Prevention and Education

• Prehospital treatment of extremity injuries that will prevent or limit compartment syndrome is immobilization, elevation, and cooling 2.
• All injured patients should be educated to seek care should the symptoms of numbness, deep pain, and coolness to the distal extremity occur 2.
• A high degree of suspicion and early decompression of all compartments at risk are important for a satisfactory outcome 6.