What is the best course of treatment for a young adult with a history of recent trauma or intense physical activity presenting with suspected compartment syndrome?

Compartment Syndrome: Immediate Fasciotomy is the Definitive Treatment

For a young adult with suspected acute compartment syndrome following recent trauma or intense physical activity, immediate surgical fasciotomy is the only definitive treatment and must be performed urgently to prevent permanent disability, limb loss, and death. 1, 2

Immediate Actions Before Surgery

Remove all constricting elements immediately:

• Cut off all casts, splints, dressings, and bandages without delay 1, 2
• Position the limb at heart level—never elevate it, as elevation reduces perfusion pressure and worsens ischemia 3, 1
• Obtain urgent orthopedic surgery consultation immediately upon clinical suspicion; do not wait for confirmatory testing if suspicion is high 2

Clinical Diagnosis: The "Four P's" Plus One

Pain out of proportion to injury is the earliest and most reliable warning sign, appearing before other symptoms 3, 1. The diagnostic approach follows this hierarchy:

Early signs (act on these):

• Severe pain disproportionate to the mechanism of injury 3, 1
• Pain with passive stretch of affected muscles (most sensitive early sign—when combined with severe pain, positive predictive value reaches 68%) 3, 1
• Paresthesia (numbness/tingling from nerve ischemia) 3, 1
• Increasing firmness/tension of the compartment on palpation 3, 1

Late signs (indicate irreversible damage has likely occurred):

• Paralysis (motor deficits) 3, 1
• Pulselessness, pallor, and coldness 3, 1

Critical pitfall: Waiting for the late signs (pulselessness, pallor, paralysis) means significant irreversible tissue damage has already occurred 3, 1, 2. These are arterial occlusion signs, not compartment syndrome diagnostic criteria 3.

When to Measure Compartment Pressure

Measure intracompartmental pressure only when clinical diagnosis remains uncertain, particularly in:

• Obtunded, sedated, or unconscious patients who cannot report pain 3, 1, 2
• Confused or uncooperative patients 1, 2
• Young children who cannot reliably communicate symptoms 1

Fasciotomy is indicated when:

• Absolute compartment pressure ≥30 mmHg 3, 1
• Differential pressure (diastolic blood pressure minus compartment pressure) ≤30 mmHg (this is the most recognized threshold in current practice) 1, 2

Use traditional needle manometry, multiparameter monitors, or dedicated transducer-tipped monitors for measurement 1. Consider continuous pressure monitoring in high-risk obtunded patients 1.

High-Risk Populations Requiring Heightened Vigilance

Monitor these patients repetitively (every 30-60 minutes) during the first 24 hours 3:

Highest risk:

• Young men under 35 years with tibial fractures (10-13 times higher incidence than women) 3, 1, 4
• Tibial shaft fractures specifically (account for 40% of all compartment syndrome cases; 4-5% of tibial fractures develop compartment syndrome) 3, 1, 4

Additional major risk factors:

• Vascular injury (dramatically increases risk and requires intensive monitoring) 3, 2
• Crush injuries or high-energy trauma 3, 4
• Hemorrhagic injury with significant bleeding 3, 2
• Patients on anticoagulation 3, 4
• Intramedullary nailing 3, 4
• Penetrating trauma 3, 4
• Burns or tourniquet use 3, 4
• Open fractures 3

Important: Compartment syndrome can occur without fracture if soft tissue damage is present 3, 1. Intense physical activity (exertional compartment syndrome) can also trigger acute compartment syndrome, particularly with underlying knee injury involving soft tissue damage or vascular compromise 4.

Surgical Management: Fasciotomy Technique

For imminent compartment syndrome (moderate perfusion disturbance, no neurological symptoms, increasing pressure):

• Subcutaneous fasciotomy with skin closure is acceptable 5

For manifest compartment syndrome (compromised circulation, loss of tissue function):

• Wide therapeutic fasciotomy with long incisions of skin and fascia 3, 5
• Split all retinacula and evacuate hematomas 5
• Excise necrotic tissue 5
• Never close the skin primarily—postoperative swelling can cause rebound compartment syndrome 5
• Perform delayed closure or mesh grafting after 4-8 days when edema decreases 1, 5

Post-Fasciotomy Management

Monitor for rhabdomyolysis complications:

• Watch for myoglobinuria (appears earlier than CPK elevation) 3, 1
• Maintain urine output >2 mL/kg/hour if myoglobinuria develops 1, 2
• Administer sodium bicarbonate to alkalinize urine (myoglobin precipitates less in alkaline urine) 2
• CPK levels >75,000 IU/L are associated with >80% incidence of acute kidney injury 3
• Consider nephrology consultation for dialysis if hyperkalemia or acute kidney injury develops 2

Wound management:

• Provide diligent wound care to facilitate closure 1
• Consider negative pressure wound therapy if not a candidate for delayed primary closure 1
• Perform second-look operation at 4-8 days for re-debridement 5

Special Considerations

Vascular injury with compartment syndrome:

• Revascularization triggers oxygen-free radical release, causing capillary leak and elevated compartment pressures 2
• Prophylactic fasciotomy at time of revascularization is reasonable in threatened but salvageable limbs to prevent delayed diagnosis 1, 2
• After prolonged ischemia (>6-8 hours), concurrent early amputation may be beneficial to avoid reperfusion morbidity in select cases 1, 2

Fluid resuscitation caution:

• Avoid aggressive crystalloid resuscitation, which increases risk of secondary abdominal compartment syndrome 3
• In severe rhabdomyolysis (CPK >15,000 IU/L), volumes >6L may be required to prevent acute kidney injury 3

Critical Pitfalls to Avoid

• Never delay surgical consultation waiting for imaging studies—compartment syndrome is a clinical diagnosis 1, 2
• Never rely solely on palpation (sensitivity only 54%, specificity 76% in children) 1
• Never elevate the limb excessively—this decreases perfusion pressure 1, 2
• Never wait for late signs (pulselessness, pallor, paralysis)—these indicate irreversible damage 3, 1
• Delays beyond 6-8 hours significantly increase risk of permanent muscle and nerve damage 2, 6
• Missing compartment syndrome in patients without fractures (can occur with soft tissue injury alone) 3, 1