Management of Arm Compartment Syndrome
Perform immediate fasciotomy of all involved compartments in the arm when compartment syndrome is diagnosed—this is the only effective treatment to prevent irreversible tissue necrosis and permanent functional impairment. 1, 2, 3
Immediate Emergency Actions
Remove all constricting elements immediately when compartment syndrome is suspected, including casts, splints, dressings, or bandages. 1, 3
Position the limb at heart level—not elevated—to maintain perfusion pressure and prevent worsening ischemia. 1, 2, 3 Excessive elevation further decreases perfusion pressure and worsens the condition. 2, 3
Arrange urgent surgical consultation for fasciotomy without delay. 1, 2, 3 Time is critical; prolonged exposure to elevated tissue pressure causes nerve and muscle necrosis. 4
Clinical Recognition
Pain out of proportion to injury is the earliest and most reliable warning sign of compartment syndrome in the arm. 1, 2, 3 However, severe pain alone gives only approximately 25% chance of correctly diagnosing compartment syndrome. 1
Pain on passive stretch of the affected muscle compartment is considered the most sensitive early sign. 1, 2, 3 When both severe pain and pain on passive stretch are present together, the positive predictive value increases to 68%. 1
Look for these additional clinical signs:
- Increasing firmness/tension of the compartment as pressure rises 1
- Paresthesia (sensory changes) from nerve ischemia 1, 2
- Paresis (motor deficits)—a late sign indicating significant tissue damage 1, 2
- Pulselessness, pallor, and decreased temperature—these are late signs indicating severe, often irreversible tissue damage 1, 2, 3
When pain, pain on passive stretch, and paralysis are all present, positive predictive value reaches 93%, but paralysis indicates irreversible muscle ischemia may have already occurred. 1
Diagnostic Approach
Compartment syndrome is primarily a clinical diagnosis based on pain out of proportion to injury and pain with passive muscle stretch. 1
Measure compartment pressures only if diagnosis remains uncertain, particularly in:
- Obtunded or sedated patients 1, 2, 3
- Confused or uncooperative patients 1
- Cases with equivocal clinical findings 3
Fasciotomy is indicated when:
- Compartment pressure ≥30 mmHg 1, 2
- Differential pressure (diastolic blood pressure minus compartment pressure) ≤30 mmHg 1, 2
- Clinical diagnosis is made based on pain out of proportion and pain on passive stretch 1
Traditional needle manometry, multiparameter monitors, or dedicated transducer-tipped intracompartmental pressure monitors can be used for pressure measurement. 1
Surgical Management
Fasciotomy must decompress all involved compartments of the arm to prevent ongoing tissue damage. 2 The arm has anterior and posterior compartments that may require decompression. 5
Surgery should be performed under general anesthesia rather than local anesthesia, and the bleeding site should be sutured or ligated—not just compressed—especially in patients on anticoagulation therapy. 5 Compression alone can allow heavy bleeding or recurrence because of anticoagulation effects. 5
Effective hemostasis in addition to early decompressive fasciotomy is essential in compartment syndrome caused by vascular procedures or in patients on anticoagulation. 5
Post-Fasciotomy Management
Monitor for myoglobinuria and maintain urine output >2 ml/kg/h if myoglobinuria develops to prevent acute kidney injury from rhabdomyolysis. 2, 3
Elevated creatine phosphokinase (CPK) levels, particularly >75,000 IU/L, are associated with high incidence of acute kidney injury (>80%). 2 Plasma myoglobin measurement may be more sensitive and specific than CPK for identifying risk of acute kidney injury. 2
Wound management strategies include:
- Consider early delayed primary closure if minimal tissue bulge is noted after fasciotomy or resolves with systemic diuresis and limb elevation 6, 2, 3
- Negative pressure wound therapy is effective to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 6, 2, 3
- Provide diligent wound care to mitigate complications (infection, nerve injury resulting in dysesthesia) and facilitate closure 6, 2, 3
Monitor for compartment syndrome recurrence, particularly in severe cases. 2, 3
High-Risk Scenarios for Arm Compartment Syndrome
Patients on anticoagulation therapy are at increased risk of developing compartment syndrome. 1, 5, 7 Spontaneous compartment syndrome can occur in patients receiving anticoagulation for conditions like atrial fibrillation. 7
Transcatheter angiography or angioplasty can cause compartment syndrome of the arm, particularly in patients with advanced atherosclerosis and on anticoagulation therapy. 5
Vascular injuries increase the risk of compartment syndrome. 1 If vascular injury is confirmed, the patient requires both revascularization and fasciotomy, as reperfusion after vascular repair significantly increases compartment syndrome risk. 2
Crush injuries, burns, and arterial injuries can result in increased tissue pressure within closed compartments. 1, 4
Strangulation injuries of the arm (such as from cable-wakeboard accidents) can cause compartment syndrome. 8
Critical Pitfalls to Avoid
Never wait for late signs (pulselessness, pallor, paralysis) as these indicate irreversible tissue damage has already occurred. 1, 2, 3 Weak pulses can result from compartment syndrome alone due to elevated tissue pressure compressing vessels. 2
Never rely solely on palpation for diagnosis—it is unreliable with sensitivity of only 54% and specificity of 76% in children. 1, 2, 3
Never elevate the limb excessively when compartment syndrome is suspected, as this further decreases perfusion pressure. 1, 2, 3
Never delay diagnosis in obtunded or sedated 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, including after vascular procedures or spontaneously in patients on anticoagulation. 1, 2, 5, 7
Never order imaging studies that delay surgical intervention. 1 Compartment syndrome is a surgical emergency requiring prompt treatment by fasciotomy. 4
Never underestimate the time-critical nature of this condition—the longer the duration of elevated tissue pressure, the greater the potential for disastrous sequelae including permanent functional impairment, renal failure, and death. 9, 4