From the Guidelines
Compartment syndrome is a medical emergency that requires immediate surgical fasciotomy to prevent permanent disability and limb loss, as evidenced by the most recent guidelines from the American College of Cardiology and American Heart Association 1.
Diagnosis and Treatment
The diagnosis of compartment syndrome is primarily clinical, with the classic signs being pain out of proportion to injury, pain on passive stretch, paresthesia, pallor, paralysis, and pulselessness (the "6 Ps"), though pulselessness is often a late finding. Compartment pressures can be measured, with absolute pressures >30 mmHg or pressures within 30 mmHg of diastolic blood pressure indicating the need for fasciotomy 1.
- Common causes include fractures, crush injuries, burns, tight casts or bandages, reperfusion after vascular surgery, and prolonged limb compression.
- Time is critical, as muscle and nerve tissue can suffer irreversible damage after 4-6 hours of ischemia.
- Post-fasciotomy, wounds are typically left open initially and may require delayed closure or skin grafting.
Prevention and Management
Prevention includes careful monitoring of at-risk patients, avoiding constrictive dressings, and prompt elevation of injured limbs. Early recognition and treatment are essential to prevent permanent disability, including contractures, sensory deficits, and even limb loss.
- Patients with severe limb trauma should be investigated repetitively for clinical signs of compartment syndrome, including pain, tension, paraesthesia, paresis, and increased compartmental pressure monitoring 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. In summary, immediate surgical fasciotomy is the definitive treatment for established compartment syndrome, and early recognition and treatment are essential to prevent permanent disability and limb loss, as supported by the most recent and highest quality studies 1.
From the Research
Definition and Diagnosis of Extremity Compartment Syndrome
- Extremity compartment syndrome is a condition where increased pressure within a closed compartment of the body leads to inadequate blood supply to the tissues inside the compartment 2.
- The diagnosis of acute compartment syndrome can be challenging, and there is no consensus on the best method for diagnosis, with some suggesting continuous monitoring of intracompartmental pressure and others recommending aggressive surgical intervention if suspected 2.
- The classical description of 'pain out of proportion to the injury' is a key clinical indicator of acute compartment syndrome, with compartment pressure monitors used as an adjunct where diagnosis is uncertain 3.
Treatment and Management of Extremity Compartment Syndrome
- Surgical fasciotomy is a common treatment for acute compartment syndrome, aiming to reduce intracompartmental pressure, but it also carries the risk of long-term complications 2.
- Hyperbaric oxygen therapy has been shown to be an effective adjunctive treatment for compartment syndrome, reducing edema and improving tissue viability 4, 5.
- The use of vacuum-assisted closure (VAC) and hyperbaric oxygen therapy (HBOT) can facilitate earlier closure of fasciotomy wounds with adjacent skin, reducing the need for skin grafts and resulting in less scarring and stronger limbs 5.
- Initial treatment of acute compartment syndrome involves removing constricting dressings or casts, avoiding hypotension, and optimizing tissue perfusion by keeping the limb at heart level, with timely surgical decompression necessary if symptoms persist 3.
Importance of Prompt Recognition and Treatment
- Acute compartment syndrome is a true orthopedic emergency, requiring swift surgical intervention to prevent long-term morbidity and potential death 6, 3.
- Prompt recognition and treatment of acute compartment syndrome are crucial to prevent irreversible ischaemic damage, which can occur within six hours of onset 3.