What is the appropriate treatment for a patient with suspected compartment syndrome?

Compartment Syndrome Treatment

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

Immediate Emergency Actions

When compartment syndrome is suspected, execute the following steps without delay:

• Remove all constricting elements immediately including dressings, casts, splints, or bandages to prevent further tissue damage 1, 3
• Position the limb at heart level (not elevated) to maintain perfusion pressure and prevent worsening ischemia 1, 3, 2
• Arrange urgent surgical consultation for fasciotomy without delay 1, 3, 2
• Measure compartment pressures only if diagnosis remains uncertain, particularly in obtunded, sedated, or uncooperative patients 1, 2

Critical Diagnostic Indicators

The diagnosis is primarily clinical:

• Pain out of proportion to injury is the earliest and most reliable warning sign 1, 3, 2
• Pain on passive stretch of the affected muscle compartment is the most sensitive early sign 1, 3, 2
• When severe pain and pain on passive stretch are both present, positive predictive value reaches 68% 1
• When pain, pain on passive stretch, AND paralysis are all present, positive predictive value reaches 93%, though paralysis indicates irreversible muscle ischemia may have already occurred 1

Surgical Intervention Criteria

Fasciotomy is indicated when:

• Compartment pressure ≥30 mmHg 1, 2
• Differential pressure (diastolic blood pressure minus compartment pressure) ≤30 mmHg 1, 2
• Clinical diagnosis based on pain out of proportion and pain on passive stretch, even without pressure measurement 1, 2

The differential pressure threshold is the most recognized cut-off for intervention in current practice 1

Fasciotomy Technique Requirements

• Decompress ALL involved compartments through long incisions of skin and fascia 2, 4
• Split retinacula and evacuate any hematoma 4
• Excise necrotic tissues if present 4
• Do not close the skin due to postoperative swelling risk, which can produce rebound compartment syndrome 4
• Perform delayed closure after 4-8 days when edema decreases, using delayed sutures or mesh graft 4

Post-Fasciotomy Management

Critical monitoring and supportive care:

• Monitor for myoglobinuria and maintain urine output >2 ml/kg/h to prevent acute kidney injury from rhabdomyolysis 5, 1, 2
• Administer sodium bicarbonate to alkalinize urine and aid potassium reuptake, as myoglobin is less likely to precipitate in alkaline urine 5
• Consider early delayed primary closure if minimal tissue bulge is noted or resolves with systemic diuresis and leg elevation 1, 2
• Apply negative pressure wound therapy for patients not candidates for delayed primary closure 1, 2
• Provide diligent wound care to mitigate complications including infection and nerve injury 1, 2
• Monitor for compartment syndrome recurrence, particularly in severe cases 1, 2

Special Populations and Contexts

After Acute Limb Ischemia Revascularization

• All patients with acute limb ischemia must be monitored for compartment syndrome after revascularization (endovascular or surgical) 5, 2
• Prophylactic fasciotomy is reasonable based on clinical findings in patients with threatened but salvageable limbs 1, 2
• Prophylactic fasciotomy should be strongly considered when time to revascularization exceeds 4 hours 2

Obtunded or Sedated Patients

• Direct compartment pressure measurement is indicated when clinical signs cannot be elicited 1, 2
• Continuous compartment pressure monitoring may be considered in high-risk, obtunded patients 1
• Measure compartment pressures earlier in these populations to avoid delayed diagnosis 1, 3

Monitoring Approach in At-Risk Patients

For patients who develop myoglobinuria (such as in malignant hyperthermia):

• Regular clinical assessment of limbs for swelling, muscle softness, and peripheral pulses or oxygen saturation 5
• Awake patients will likely complain of pain if compartment syndrome develops 5
• Measure compartmental pressures if any suspicion exists 5
• Remember that creatine kinase levels may not peak for up to 24 hours after the inciting event 5

Critical Pitfalls to Avoid

Never wait for late signs such as pulselessness, pallor, or paralysis, as these indicate significant irreversible tissue damage has already occurred 1, 3, 2

Never rely solely on palpation for diagnosis, as it is unreliable with sensitivity of only 54% and specificity of 76% in children 1, 3, 2

Never elevate the limb excessively when compartment syndrome is suspected, as this further decreases perfusion pressure and worsens ischemia 1, 3, 2

Never delay diagnosis in obtunded patients, as this leads to poor outcomes—measure compartment pressures earlier in these populations 1, 3

Never miss compartment syndrome in patients without fractures, as it can occur with soft tissue injuries alone 1, 2

Never order imaging studies that delay surgical intervention 1