What are the signs, symptoms, and treatment for compartment syndrome?

From the Guidelines

Compartment syndrome is a medical emergency that requires immediate surgical intervention through fasciotomy to relieve pressure within the affected compartment, as indicated by the most recent guidelines 1. The definitive treatment involves making incisions in the fascia to decompress the compartment, allowing blood flow to resume and preventing tissue death. Prior to surgery, remove any restrictive dressings, casts, or clothing from the affected limb and position it at heart level (not elevated) as suggested by 1. Signs and symptoms of compartment syndrome include:

• Severe pain out of proportion to the injury that worsens with passive stretching
• Paresthesia (pins and needles sensation)
• Pallor
• Pulselessness
• Paralysis (the "6 Ps") Pain and paresthesia are early signs, while pulselessness and paralysis are late findings indicating severe compromise. Compartment pressure measurements above 30 mmHg or within 30 mmHg of diastolic blood pressure confirm the diagnosis, as stated in 1. The condition occurs when increased pressure within a closed fascial space compromises circulation and nerve function, commonly following fractures, crush injuries, burns, or reperfusion after ischemia. Without prompt treatment, permanent muscle and nerve damage can occur within 4-6 hours, potentially leading to limb loss or life-threatening complications like rhabdomyolysis and kidney failure, highlighting the importance of early intervention as recommended by 1. In patients with acute limb ischemia (ALI), prophylactic fasciotomy is reasonable based on clinical findings, and concurrent and early amputation can be beneficial to avoid the morbidity of reperfusion, as suggested by 1.

From the Research

Treatment of Compartment Syndrome

• The primary treatment for compartment syndrome is surgical intervention to decompress the affected area, which is often the only effective treatment 2.
• Fasciotomy is the surgical procedure used to release the affected compartment and should be performed as early as possible to prevent irreversible ischemic damage to muscles and peripheral nerves 3.
• The timing of decompression is crucial and can be stratified into four categories: immediate, early, delayed, and prophylactic decompression 2.
• Immediate decompression is necessary for compartmental syndromes that can lead to patient death or extreme disability if left untreated 2.
• Early decompression should be performed within 3-12 hours of symptom onset, before clinical signs of irreversible deterioration occur 2.

Signs and Symptoms of Compartment Syndrome

• The diagnosis of compartment syndrome is largely clinical, with the classical description of 'pain out of proportion to the injury' being a key indicator 4.
• Other signs and symptoms include increased interstitial pressure, impaired local circulation, and pain on palpation of the affected area 3.
• Compartment pressure monitors can be used as an adjunct to clinical diagnosis, with an intracompartmental pressure higher than 30 mmHg of diastolic blood pressure being significant of compartment syndrome 3.
• The condition can occur in various body regions, including the legs, arms, hands, feet, and buttocks, and can be caused by severe injury, such as fractures or crush injuries, or by relatively minor injuries or iatrogenic causes 3.

Management and Outcome

• The management of compartment syndrome involves prompt evaluation and treatment, with the goal of preventing long-term morbidity and mortality 4.
• Initial treatment includes the removal of constricting dressings or casts, avoiding hypotension, and optimizing tissue perfusion by keeping the limb at heart level 4.
• Definitive treatment involves timely surgical decompression of all involved compartments, with the aim of preventing irreversible ischemic damage 4.
• Wound closure following fasciotomy can be achieved through various methods, including gradual approximation techniques, negative pressure therapy, and skin grafting 5.
• The outcome of compartment syndrome treatment can be significant, with complications including lower extremity nerve deficit, wound infection, and amputation 6.