What is the best course of treatment for a patient with suspected compartment syndrome, considering potential neurovascular compromise and the need for prompt intervention to prevent long-term damage?

Compartment Syndrome: Immediate Fasciotomy is the Only Definitive Treatment

Immediate fasciotomy of all involved compartments is the only effective treatment when compartment syndrome is diagnosed, and must be performed urgently to prevent irreversible tissue necrosis, permanent functional impairment, and potential death. 1, 2, 3

Clinical Recognition and Diagnosis

Early Warning Signs (Act on These)

• Pain out of proportion to injury is the earliest and most reliable warning sign and should trigger immediate action 1, 2, 3
• Pain on passive stretch of the affected muscle compartment is the most sensitive early sign and warrants urgent intervention 1, 2
• Increasing firmness/tension of the compartment indicates rising intracompartmental pressure 1
• Paresthesias (sensory changes) result from nerve ischemia 1

Late Signs (Indicate Irreversible Damage Has Already Occurred)

• Paralysis (motor deficits), pulselessness, pallor, and decreased temperature are late signs indicating significant tissue damage has already occurred 1, 2, 3
• Never wait for these late signs—irreversible tissue damage occurs within 6 hours of established compartment syndrome 2

Diagnostic Limitations

• Clinical signs alone have low sensitivity (25% with severe pain alone) but high specificity 1
• 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
• Palpation is unreliable in isolation (sensitivity 54%, specificity 76% in children) 1, 2, 3

Immediate Management Algorithm

Step 1: Remove All Constricting Elements Immediately

• Remove all dressings, casts, splints, or bandages immediately when compartment syndrome is suspected 1, 2, 3
• This is the most important immediate measure before definitive treatment 4

Step 2: Position the Limb Correctly

• Position the limb at heart level (not elevated) to maintain perfusion pressure 1, 2, 3
• Excessive elevation further decreases perfusion pressure and worsens ischemia 1, 2, 3

Step 3: Arrange Urgent Surgical Consultation

• Arrange urgent surgical consultation for fasciotomy without delay 1, 2, 3
• Never order imaging studies that delay surgical intervention 1

Step 4: Measure Compartment Pressures (Only If Diagnosis Uncertain)

• Measure compartment pressures only if diagnosis remains in doubt, particularly in obtunded, sedated, or uncooperative patients 1, 2, 3
• Use traditional needle manometry, multiparameter monitors, or dedicated transducer-tipped intracompartmental pressure monitors 1
• Fasciotomy is indicated when compartment pressure ≥30 mmHg or when differential pressure (diastolic blood pressure minus compartment pressure) is ≤30 mmHg 1, 2, 3
• The differential pressure threshold is the most recognized cut-off for intervention in current practice 1

Definitive Surgical Treatment

Fasciotomy Technique

• Immediate fasciotomy of all involved compartments is required 1, 2, 3
• For the lower leg, decompress all four compartments (anterior, lateral, superficial posterior, and deep posterior) 2
• Long incisions of skin and fascia are required, with splitting of retinacula and excision of necrotic tissues 4
• Skin closure is not permitted immediately because of postoperative swelling, which can produce rebound compartment syndrome 4

Timing

• Irreversible tissue damage can occur within 6 hours of established compartment syndrome 2
• Prolonged ischemia (>6-8 hours) significantly increases the risk of irreversible tissue damage and need for amputation 2

Post-Fasciotomy Management

Wound Management

• After 4-8 days, edema decreases and the wound can be closed by delayed sutures or mesh graft 4
• Consider early delayed primary closure if minimal tissue bulge is noted after fasciotomy or resolves with systemic diuresis and leg elevation 1, 2
• Negative pressure wound therapy is effective to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 1, 2, 3

Monitoring for Complications

• Monitor for myoglobinuria and maintain urine output >2 ml/kg/h to prevent acute kidney injury from rhabdomyolysis 5, 1, 2, 3
• Elevated creatine phosphokinase (CPK) levels, particularly >75,000 IU/L, are associated with high incidence of acute kidney injury (>80%) 2
• Monitor for compartment syndrome recurrence, particularly in severe cases 1, 2
• Monitor for disseminated intravascular coagulopathy, infection of fasciotomy wounds, and nerve injury resulting in dysesthesia 1

High-Risk Populations Requiring Heightened Vigilance

• Young men under 35 years with tibial fractures 1
• Patients with fractures (especially tibial shaft fractures), crush injuries, or high-energy trauma 1
• Patients with vascular injuries, burns, or on anticoagulation 1
• Patients undergoing revascularization for acute limb ischemia—all must be monitored for compartment syndrome after revascularization 2
• Patients with Category IIb ischemia for whom time to revascularization exceeds 4 hours should be considered for prophylactic fasciotomy 2

Special Considerations After Acute Limb Ischemia

• Monitor all patients with acute limb ischemia for compartment syndrome after revascularization (endovascular or surgical) 5, 2
• Prophylactic fasciotomy is reasonable based on clinical findings in patients with acute limb ischemia with a threatened but salvageable limb 1, 2
• Prophylactic fasciotomy at the time of revascularization should be strongly considered for patients with Category IIb ischemia when time to revascularization exceeds 4 hours 2

Critical Pitfalls to Avoid

• Never wait for late signs (pulselessness, pallor, paralysis)—these indicate irreversible tissue damage has already occurred 1, 2, 3
• Never rely solely on palpation for diagnosis—it is unreliable 1, 2, 3
• Never elevate the limb excessively—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 1, 2
• Never delay anticoagulation or surgical intervention while arranging diagnostic imaging 2
• Never underestimate the risk of compartment syndrome after revascularization—maintain high clinical suspicion 2