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

Immediate Emergency Management Algorithm

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

1. Remove all constricting elements immediately - including dressings, casts, splints, or bandages to prevent further tissue damage 1, 2

2. Position the limb at heart level (not elevated) - excessive elevation further decreases perfusion pressure and worsens ischemia 1, 2

3. Arrange urgent surgical consultation for fasciotomy without delay - this is a surgical emergency requiring immediate intervention 1, 2

4. Measure compartment pressures only if diagnosis remains uncertain - particularly in obtunded, sedated, or uncooperative patients who cannot reliably report pain 1

Clinical Recognition: The "5 P's" Hierarchy

Understanding the temporal progression of signs is critical to avoid devastating outcomes:

Early Signs (Act on These):

• Pain out of proportion to injury - the earliest and most reliable warning sign 1, 3
• Pain on passive stretch of the affected muscle compartment - the most sensitive early sign 1, 3
• Increasing firmness/tension of the compartment as pressure rises 1

Late Signs (Indicate Irreversible Damage):

• Paresthesia (sensory changes) from nerve ischemia 1
• Paralysis (motor deficits) - indicates significant tissue damage has already occurred 1
• Pulselessness, pallor, and decreased temperature - severe tissue damage is present 1

Diagnostic Performance

• Severe pain alone provides only 25% positive predictive value for compartment syndrome 1
• Pain plus pain on passive stretch increases positive predictive value to 68% 1
• Pain, pain on passive stretch, and paralysis together reach 93% positive predictive value, but paralysis indicates irreversible muscle ischemia may have already occurred 1

Compartment Pressure Measurement (When Needed)

Indications for pressure measurement:

• Diagnosis remains uncertain after clinical assessment 1
• Obtunded or sedated patients who cannot report pain 1
• Uncooperative patients with equivocal clinical findings 2

Measurement techniques:

• Use traditional needle manometry, multiparameter monitors, or dedicated transducer-tipped intracompartmental pressure monitors 1

Fasciotomy thresholds:

• Compartment pressure ≥30 mmHg 1
• Differential pressure (diastolic blood pressure minus compartment pressure) ≤30 mmHg - this is the most recognized cut-off for intervention in current practice 1

Definitive Surgical Treatment

Perform immediate fasciotomy of all involved compartments when compartment syndrome is diagnosed - this is the only effective treatment to prevent irreversible tissue damage 1, 2

Surgical approach:

• Long incisions of skin and fascia 4
• Splitting of retinacula 4
• Excision of necrotic tissues 4
• Evacuation of hematoma 4
• Rigid fixation of fractures if possible 4
• Do not close skin - postoperative swelling can produce rebound compartment syndrome 4

Post-Fasciotomy Management

Rhabdomyolysis prevention:

• Monitor for myoglobinuria and maintain urine output >2 ml/kg/h to prevent acute kidney injury 1, 2
• Administer sodium bicarbonate to alkalinize urine - myoglobin is less likely to precipitate in alkaline urine 1

Wound management:

• After 4-8 days when edema decreases, close wound by delayed sutures or mesh graft 4
• Consider early delayed primary closure if minimal tissue bulge is noted or resolves with systemic diuresis and leg elevation 1
• Use negative pressure wound therapy to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 1
• Provide diligent wound care to mitigate complications including infection, nerve injury, and dysesthesia 1

High-Risk Populations Requiring Heightened Vigilance

• Young men under 35 years with tibial fractures 1
• Patients with fractures, especially tibial shaft fractures 1
• Patients with crush injuries or high-energy trauma 1
• Patients with vascular injuries or burns 1
• Patients on anticoagulation 1
• Motorcyclists who suffer lower-extremity injuries 5

Critical Pitfalls to Avoid

Never wait for late signs (pulselessness, pallor, paralysis) - these indicate significant irreversible tissue damage has already occurred 1, 2, 3

Never rely solely on palpation for diagnosis - sensitivity is only 54% and specificity is 76% in children, making it unreliable 1, 3

Never elevate the limb excessively - this further decreases perfusion pressure and worsens compartment syndrome 1, 2, 3

Never delay diagnosis in obtunded patients - earlier compartment pressure measurement is essential as these patients cannot report pain 1, 2

Never order imaging studies that delay surgical intervention - compartment syndrome is a clinical diagnosis requiring immediate fasciotomy 1

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

Special Considerations

For abdominal compartment syndrome:

• Measure intra-abdominal pressure (IAP) 6
• Avoid sustained intra-abdominal hypertension 6
• Implement protocolized IAP monitoring and management 6
• Perform decompressive laparotomy for overt abdominal compartment syndrome 6
• Use negative pressure wound therapy and efforts to achieve same-hospital-stay fascial closure among patients with open abdomen 6