What is the best course of treatment for a patient with compartment syndrome resulting from a severe sprain?

Compartment Syndrome from Severe Sprain: Treatment Algorithm

Immediate fasciotomy of all involved compartments is the definitive treatment for compartment syndrome, regardless of whether it results from a fracture or soft tissue injury like a severe sprain. 1, 2

Immediate Actions (Do Not Delay)

When compartment syndrome is suspected from a severe sprain:

• Remove all constricting dressings, wraps, splints, or compression devices immediately to eliminate external compression that worsens compartmental pressure 1
• Position the limb at heart level (not elevated, as elevation decreases perfusion pressure and worsens ischemia) 1
• Arrange urgent surgical consultation for fasciotomy without delay 1

Clinical Diagnosis Framework

The diagnosis is primarily clinical and should not wait for confirmatory testing:

• Pain out of proportion to the injury is the earliest and most reliable warning sign, though it only provides approximately 25% positive predictive value in isolation 1
• Pain with passive stretch of the affected muscle compartment increases diagnostic accuracy to 68% when combined with severe pain 1
• When pain, pain on passive stretch, AND paralysis are all present, positive predictive value reaches 93%, but paralysis indicates irreversible muscle ischemia has already occurred 1
• Late signs (pulselessness, pallor, paresthesia, paralysis) indicate significant tissue damage has already begun and represent a surgical emergency 1, 2

When to Measure Compartment Pressure

• Measure compartment pressures only if clinical diagnosis remains uncertain, particularly in obtunded, confused, sedated, or uncooperative patients who cannot reliably report pain 1
• Never delay surgical intervention to obtain pressure measurements if clinical diagnosis is clear 1
• Use traditional needle manometry, multiparameter monitors, or dedicated transducer-tipped monitors 1

Fasciotomy Indications (Absolute Thresholds)

Perform immediate fasciotomy when:

• Compartment pressure ≥30 mmHg 1
• Differential pressure (diastolic blood pressure minus compartment pressure) ≤30 mmHg - this is the most recognized threshold in current practice 1
• Clinical diagnosis is clear based on pain out of proportion plus pain on passive stretch, even without pressure measurement 1

Critical Timing Considerations

• Muscles tolerate 4 hours of ischemia well, but outcomes are uncertain by 6 hours, and damage is irreversible after 8 hours 3
• Ischemic injury begins when tissue pressure rises to within 10-20 mmHg of diastolic pressure 3
• Time from symptom onset to fasciotomy directly correlates with permanent functional impairment 4, 5

Post-Fasciotomy Management

After surgical decompression:

• Monitor for myoglobinuria and maintain urine output >2 mL/kg/h if myoglobinuria develops to prevent acute kidney injury from rhabdomyolysis 2
• Consider early delayed primary closure if minimal tissue bulge occurs with systemic diuresis and leg elevation 1
• Use negative pressure wound therapy to reduce discomfort and facilitate closure when delayed primary closure is not feasible 1
• Provide diligent wound care to mitigate infection risk 1
• Monitor for compartment syndrome recurrence, particularly in severe cases 1

Common Pitfalls to Avoid

• Never wait for late signs (pulselessness, pallor, paralysis) before intervening, as these indicate irreversible damage is occurring 1, 2
• Never rely solely on palpation for diagnosis (sensitivity only 54%, specificity 76%) 1
• Never elevate the limb excessively, as this decreases perfusion pressure and worsens ischemia 1
• Never order imaging studies that delay surgical intervention 1
• Do not miss compartment syndrome in patients without fractures - soft tissue injuries alone (including severe sprains) can cause compartment syndrome 1, 6

Special Consideration for Sprains

While compartment syndrome is classically associated with fractures and crush injuries, severe sprains with significant soft tissue damage, hemorrhage into the compartment, or vascular compromise can trigger compartment syndrome 6, 7. The treatment algorithm remains identical regardless of mechanism - immediate fasciotomy when diagnosed 1, 2.