Compartment syndrome: Difference between revisions

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==Pathophysiology==
==Background==
*Increased pressure within a closed fascial compartment compromising perfusion to muscles and nerves
*'''Surgical emergency''' — irreversible damage begins within '''6-8 hours''' of ischemia
*Most common location: anterior compartment of the leg (tibia fractures)
*Causes:
**Fractures (most common — especially tibia, forearm, supracondylar humerus in children)
**Crush injuries, reperfusion injury after vascular repair
**Burns (circumferential), tight casts/splints/dressings
**Hemorrhage (anticoagulation), [[rhabdomyolysis]]
**Envenomation ([[snakebite]])
**IV/IO infiltration
*Normal tissue pressure: 0-8 mmHg
*Ischemia begins when compartment pressure exceeds capillary perfusion pressure


==Clinical Features==
*The 6 P's (pain is earliest and most reliable; pulselessness is latest):
**Pain — out of proportion to exam (most sensitive early finding)
**Pain with passive stretch of muscles in affected compartment (most sensitive exam finding)
**Pressure — tense, firm compartment on palpation
**Paresthesias — indicates nerve ischemia
**Paralysis — late finding; indicates significant ischemia
**Pulselessness — very late finding; presence of pulses does NOT exclude compartment syndrome
*Key pearls:
**Increasing analgesic requirements should raise suspicion
**Normal pulses and capillary refill do NOT rule out compartment syndrome
**'''Obtunded, intubated, or pediatric patients''' cannot report pain — maintain '''high index of suspicion'''


Cycle: Increased pressure-->impaired perfusion-->disruption of cellular metabolism-->cytolysis with release of osmotically active contents into compartment-->additional fluid drawn into compartment-->increased pressure
==Differential Diagnosis==
*[[Deep vein thrombosis]]
*[[Cellulitis]] / [[necrotizing fasciitis]]
*Fracture pain
*Peripheral vascular injury
*Neuropraxia
*[[Rhabdomyolysis]] without compartment syndrome
*Acute [[arterial occlusion]]


== ==
==Evaluation==
===Clinical Diagnosis===
*Compartment syndrome is primarily a CLINICAL diagnosis
*Serial examinations are essential
*'''Do not delay fasciotomy for pressure measurement''' if clinical picture is clear


===Compartment Pressure Measurement===
*Indicated when clinical exam is unreliable (obtunded, pediatric, equivocal exam)
*Methods: Stryker needle (most common in ED), arterial line transducer
*Absolute pressure >30 mmHg: concerning
*Delta pressure (diastolic BP minus compartment pressure) <30 mmHg: indicates need for fasciotomy<ref>McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures: the pressure threshold for decompression. ''J Bone Joint Surg Br''. 1996;78(1):99-104. PMID 8898137</ref>
*'''Delta pressure is more reliable than absolute pressure''' (accounts for patient's perfusion status)
*Measure all compartments in the affected extremity (leg has 4: anterior, lateral, deep posterior, superficial posterior)


==Presentation==
===Labs===
*CK (elevated in [[rhabdomyolysis]])
*BMP (monitor renal function, [[hyperkalemia]])
*Urinalysis (myoglobinuria)


==Management==
===Immediate===
*'''Remove all circumferential dressings, casts, and splints''' immediately
*Keep extremity at heart level (elevation may decrease arterial perfusion; dependent position worsens edema)
*Avoid hypotension — maintain adequate perfusion pressure
*IV fluid resuscitation if rhabdomyolysis


-5 Ps: pain, paresthesias, pallor, poikilothermia, pulselessness
===Fasciotomy===
*Definitive treatment — emergent surgical consultation
*Four-compartment fasciotomy for lower leg
*Delay >6-8 hours: significantly increased risk of permanent neuromuscular damage, amputation
*'''Do NOT delay for imaging''' if diagnosis is clinically apparent
*Wound typically left open with delayed primary closure or skin grafting at 48-72 hours


NB: pain, paresthesias are NOT reliable
===Post-Fasciotomy Monitoring===
*Serial CK, renal function, electrolytes
*Monitor for reperfusion injury ([[hyperkalemia]], [[metabolic acidosis]], [[rhabdomyolysis]])
*Broad-spectrum antibiotics if contaminated wound


-Pain at rest or with passive ROM
==Disposition==
*All suspected cases require admission and emergent orthopedic/surgical consultation
*ICU if [[rhabdomyolysis]] or hemodynamic instability
*Missed compartment syndrome is a significant medicolegal risk


-Sensory nerves are first to lose conductive ability
==See Also==
*[[Rhabdomyolysis]]
*[[Fractures]]
*[[Crush syndrome]]
*[[Snakebite]]


== ==
==References==
<references/>
*Via AG, et al. Acute compartment syndrome. ''Muscles Ligaments Tendons J''. 2015;5(1):18-22. PMID 25878982
*Shadgan B, et al. Diagnostic techniques in acute compartment syndrome of the leg. ''J Orthop Trauma''. 2008;22(8):581-587. PMID 18758292
*Schmidt AH. Acute compartment syndrome. ''Orthop Clin North Am''. 2016;47(3):517-525. PMID 27241376


 
[[Category:Orthopedics]]
Etiology==
 
 
Most often develops soon after significant trauma  (particularly involving long bone fractures of the lower leg or forearm)
 
May also occur following minor trauma or from  nontraumatic causes:
 
-ischemia-reperfusion  injury
 
-coagulopathy
 
-certain  animal envenomations and bites
 
-extravasation  of IV fluids
 
-injection of recreational drugs
 
-prolonged limb compression
 
== ==
 
 
==Diagnosis==
 
 
Non-invasive tests are NOT reliable
 
Striker
 
Normal = 0-8mm Hg
 
Capillary blod flow starts to be compromised at 20mmHg
 
-Symptoms and signs may develop with pressures above approximately 20  mmHg
 
Muscles and nerve fibers at risk at >30-40mmHg
 
*interpret in light of SBP
 
-The pressure necessary for injury varies
 
-Higher pressures may be necessary with systemic hypertension
 
-May develop at lower pressures in those with hypotension or peripheral vascular disease
 
-A single normal compartment pressure reading, early in the course of the disease, does NOT rule out comp sy.
 
-Serial or continuous measurements are important when patient risk is moderate to high or clinical suspicion exists.
 
 
==Specific Syndromes==
 
 
I.  Forearm (<5%)
 
(most frequent injuries associated with comp sy in forearm are supracondylar humerus fractures in children and distal radius fractures in adults)
 
1) deep volar
 
-at highest risk for comp sy
 
-contains the digital flexors
 
-decreased wrist extension
 
-includes flexor digitorum profundus (responsible for distal interphalangeal joint flexion) and the flexor pollicis longus (responsible for interphalangeal joint flexion of the thumb)
 
2) superficial volar
 
3) dorsal
 
-contains the digital extensors
 
4) lateral
 
 
II. Lower (Leg 2-12% tibia)
 
1) Anterior
 
-most common site compartment sy
 
-contains the four extensor muscles of the foot, the anterior tibial artery, and the deep peroneal nerve
 
-sx include loss of sensation between the 1st and 2nd toes and weakness of foot dorsiflexion
 
-late sequelae include foot drop, claw foot, and deep peroneal nerve dysfunction
 
2) Lateral
 
-contains muscles for foot eversion and some plantar flexion (ie, peroneus brevis, peroneus longus), the peroneal artery, the superficial peroneal nerve, and the proximal portion of the deep peroneal nerve
 
-sx include deep peroneal nerve deficit (weakness in dorsiflexion and inversion of the foot and sensory loss in the web space between the great toe and the adjacent toe)
 
-superficial peroneal nerve also travels through this compartment and supplies sensation to the lower leg and foot
 
3) Deep posterior
 
-muscles that aid in foot plantar flexion, as well as the posterior tibial artery, peroneal artery, and the tibial nerve
 
-sx include plantar hypesthesia, weakness of toe flexion, and pain with passive extension of the toes
 
4) Superficial posterior
 
-the major muscles of plantar flexion (ie, gastrocnemius, soleus)
 
-no major arteries or nerves in this compartment.
 
-least likely to develop ACS in lower leg
 
-sx include pain and a palpably tense and tender compartment
 
 
==Treatment==
 
 
Raise limb to level of heart
 
AVOID ice (will further compromise microcirculation)
 
Bivalve or remove cast if present
 
Surgery consult
 
Definitive: Fasciotomy
 
Goal: < 6hours
 
 
==Source==
 
 
Adapted from KajiQuestions and Donaldson; Perron (ACEP '09)
 
 
 
 
[[Category:Ortho]]

Latest revision as of 09:31, 22 March 2026

Background

  • Increased pressure within a closed fascial compartment compromising perfusion to muscles and nerves
  • Surgical emergency — irreversible damage begins within 6-8 hours of ischemia
  • Most common location: anterior compartment of the leg (tibia fractures)
  • Causes:
    • Fractures (most common — especially tibia, forearm, supracondylar humerus in children)
    • Crush injuries, reperfusion injury after vascular repair
    • Burns (circumferential), tight casts/splints/dressings
    • Hemorrhage (anticoagulation), rhabdomyolysis
    • Envenomation (snakebite)
    • IV/IO infiltration
  • Normal tissue pressure: 0-8 mmHg
  • Ischemia begins when compartment pressure exceeds capillary perfusion pressure

Clinical Features

  • The 6 P's (pain is earliest and most reliable; pulselessness is latest):
    • Pain — out of proportion to exam (most sensitive early finding)
    • Pain with passive stretch of muscles in affected compartment (most sensitive exam finding)
    • Pressure — tense, firm compartment on palpation
    • Paresthesias — indicates nerve ischemia
    • Paralysis — late finding; indicates significant ischemia
    • Pulselessness — very late finding; presence of pulses does NOT exclude compartment syndrome
  • Key pearls:
    • Increasing analgesic requirements should raise suspicion
    • Normal pulses and capillary refill do NOT rule out compartment syndrome
    • Obtunded, intubated, or pediatric patients cannot report pain — maintain high index of suspicion

Differential Diagnosis

Evaluation

Clinical Diagnosis

  • Compartment syndrome is primarily a CLINICAL diagnosis
  • Serial examinations are essential
  • Do not delay fasciotomy for pressure measurement if clinical picture is clear

Compartment Pressure Measurement

  • Indicated when clinical exam is unreliable (obtunded, pediatric, equivocal exam)
  • Methods: Stryker needle (most common in ED), arterial line transducer
  • Absolute pressure >30 mmHg: concerning
  • Delta pressure (diastolic BP minus compartment pressure) <30 mmHg: indicates need for fasciotomy[1]
  • Delta pressure is more reliable than absolute pressure (accounts for patient's perfusion status)
  • Measure all compartments in the affected extremity (leg has 4: anterior, lateral, deep posterior, superficial posterior)

Labs

Management

Immediate

  • Remove all circumferential dressings, casts, and splints immediately
  • Keep extremity at heart level (elevation may decrease arterial perfusion; dependent position worsens edema)
  • Avoid hypotension — maintain adequate perfusion pressure
  • IV fluid resuscitation if rhabdomyolysis

Fasciotomy

  • Definitive treatment — emergent surgical consultation
  • Four-compartment fasciotomy for lower leg
  • Delay >6-8 hours: significantly increased risk of permanent neuromuscular damage, amputation
  • Do NOT delay for imaging if diagnosis is clinically apparent
  • Wound typically left open with delayed primary closure or skin grafting at 48-72 hours

Post-Fasciotomy Monitoring

Disposition

  • All suspected cases require admission and emergent orthopedic/surgical consultation
  • ICU if rhabdomyolysis or hemodynamic instability
  • Missed compartment syndrome is a significant medicolegal risk

See Also

References

  1. ↑ McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures: the pressure threshold for decompression. J Bone Joint Surg Br. 1996;78(1):99-104. PMID 8898137
  • Via AG, et al. Acute compartment syndrome. Muscles Ligaments Tendons J. 2015;5(1):18-22. PMID 25878982
  • Shadgan B, et al. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma. 2008;22(8):581-587. PMID 18758292
  • Schmidt AH. Acute compartment syndrome. Orthop Clin North Am. 2016;47(3):517-525. PMID 27241376
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