From the Guidelines
The workup for compartment syndrome involves a high index of suspicion based on clinical presentation, followed by compartment pressure measurements, and immediate fasciotomy is required if the diagnosis is confirmed or highly suspected, as delayed treatment can lead to permanent neurovascular damage, muscle necrosis, contractures, and even limb loss. Patients typically present with pain out of proportion to injury, pain on passive stretch, paresthesias, pallor, paralysis, and pulselessness (the "6 Ps"), though pulselessness is often a late finding 1. When compartment syndrome is suspected, immediate measurement of compartment pressures should be performed using a pressure monitor or manometer, with a delta pressure (diastolic blood pressure minus compartment pressure) less than 30 mmHg or an absolute compartment pressure greater than 30-45 mmHg being diagnostic 1.
Key Considerations
- Clinical signs of compartment syndrome, including pain, paresthesia, paresis, and pain with stretch, should be monitored closely, especially in patients with severe limb trauma or crush injury 1
- The presence of multiple clinical signs increases the likelihood of a positive diagnosis of compartment syndrome, but the absence of clinical signs is more accurate in excluding the condition 1
- Continuous pressure monitoring may be necessary in unconscious patients or those unable to communicate symptoms, and laboratory tests including creatine kinase and myoglobin can help assess muscle damage but should not delay diagnosis 1
- Imaging studies like ultrasound or MRI may show muscle swelling but are not reliable for diagnosis and should not delay treatment 1
Management
- Immediate fasciotomy is required to prevent irreversible tissue damage, which can occur within 4-6 hours of onset, and the diagnosis is primarily clinical, with a low threshold for surgical intervention if there is a high suspicion of compartment syndrome 1
- Prophylactic fasciotomy may be reasonable in patients with acute limb ischemia and a threatened but salvageable limb, based on clinical findings 1
- Concurrent and early amputation can be beneficial in patients with acute limb ischemia and prolonged ischemia, to avoid the morbidity of reperfusion injury 1
From the Research
Diagnosis of Compartment Syndrome
- The diagnosis of compartment syndrome is largely clinical, with the classical description of 'pain out of proportion to the injury' 2
- Compartment pressure monitors can be a helpful adjunct where the diagnosis is in doubt 2
- Diagnosis is made on the basis of physical examination and repeated intracompartmental pressure (ICP) measures, with ICP higher than 30 mmHg of diastolic blood pressure being significant of compartment syndrome 3
- Supplemental methods such as infrared spectroscopy, and ultrasound can provide additional information that support decision-making 4
Treatment of Compartment Syndrome
- 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 2
- Definitive treatment is necessary with timely surgical decompression of all the involved compartments if symptoms persist 2
- Fasciotomy to release the affected compartment should be performed as early as possible because delayed decompression would lead to irreversible ischemic damage to muscles and peripheral nerves 3
Prevention of Compartment Syndrome
- Prehospital treatment of extremity injuries that will prevent or limit compartment syndrome is immobilization, elevation and cooling 5
- Recognition of the syndrome later in its course requires the removal of the patient to an appropriate emergency department 5
- All injured patients should be educated to seek care should the symptoms of numbness, deep pain and coolness to the distal extremity occur 5
Monitoring and Diagnosis
- Subfascial pressures should be monitored in patients at risk of compartment syndrome, such as those with pitviper envenomation 6
- Earlier monitoring of subfascial pressures and using those pressures as a guide for decisions about time and dose of treatment may have permitted earlier surgical treatment after onset of compartment syndrome or even prevented the onset of this condition 6