Compartment syndrome: Difference between revisions
(Major update: delta pressure criteria, 6 Ps with clinical pearls, fasciotomy timing, obtunded patient considerations, medicolegal note, references with PMIDs)
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==Background==
==Background==
*Most commonly caused by tibia fracture (anterior compartment)
*Increased pressure within a closed fascial compartment compromising perfusion to muscles and nerves
 
*'''Surgical emergency''' — irreversible damage begins within '''6-8 hours''' of ischemia
{{Compartment Syndrome Indications}}
*Most common location: '''anterior compartment of the leg''' (tibia fractures)
 
*Causes:
===Pathophysiology===
**'''Fractures''' (most common — especially tibia, forearm, supracondylar humerus in children)
*Tissue perfusion is difference between diastolic BP and compartment pressure
**Crush injuries, reperfusion injury after vascular repair
**As compartment pressure increases, tissue perfusion decreases
**Burns (circumferential), tight casts/splints/dressings
 
**Hemorrhage (anticoagulation), [[rhabdomyolysis]]
===Etiologies===
**Envenomation ([[snakebite]])
*Orthopedic
**IV/IO infiltration
**[[Tibial fracture]]
*Normal tissue pressure: 0-8 mmHg
**[[Forearm fracture]]
*'''Ischemia begins when compartment pressure exceeds capillary perfusion pressure'''
*Vascular
**Ischemic-reperfusion injury  
**Hemorrhage
***Can be spontaneous in anticoagulated patients
*Iatrogenic
**Vascular puncture in anticoagulated patients
**IV/intra-arterial drug injection
**Constrictive casts
*Soft tissue injury
**Prolonged limb compression
**[[Crush injury]]  
**[[Burn]]
**[[Snake bite]]
**Expanding hematoma


==Clinical Features==
==Clinical Features==
===General Symptoms===
*'''The 6 P's''' (pain is earliest and most reliable; pulselessness is latest):
*Compartment is swollen, firm, tender with squeezing
**'''Pain''' — '''out of proportion to exam''' (most sensitive early finding)
*Usually develops soon after significant trauma
**'''Pain with passive stretch''' of muscles in affected compartment (most sensitive exam finding)
**May be delayed up to 48hr after the event
**'''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'''


====5 P's====
==Differential Diagnosis==
*Classic signs of disruption in arterial flow, not of compartment syndrome  
*[[Deep vein thrombosis]]
**Only found once arterial flow has stopped (very late finding)
*[[Cellulitis]] / [[necrotizing fasciitis]]
*Fracture pain
*Peripheral vascular injury
*Neuropraxia
*[[Rhabdomyolysis]] without compartment syndrome
*Acute [[arterial occlusion]]


#Pain (early finding)
==Evaluation==
#*Severe, out of proportion to physical findings
===Clinical Diagnosis===
#*Worse with passive stretch of distal body part such as toes or fingers (muscle extension > increased volume > increased pressure)
*'''Compartment syndrome is primarily a CLINICAL diagnosis'''
#*Often the presenting symptom.
*Serial examinations are essential
#Paresthesia (early finding)
*'''Do not delay fasciotomy for pressure measurement''' if clinical picture is clear
#*Occurs in sensory distribution of affected nerve
#Pallor
#Paralysis: late finding
#Pulselessness: late finding


===Lower Leg Specific Syndromes===
===Compartment Pressure Measurement===
*Anterior
*'''Indicated when clinical exam is unreliable''' (obtunded, pediatric, equivocal exam)
**Nerve: deep fibular (peroneal): sensation of 1st webspace
*Methods: Stryker needle (most common in ED), arterial line transducer
**Muscle: tibialis anterior: foot/ankle dorsiflexion
*'''Absolute pressure >30 mmHg''': concerning
*Lateral
*'''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>
**Nerve: superficial fibular (peroneal) nerve: sensation of lateral aspect of lower leg, dorsum of foot
*'''Delta pressure is more reliable than absolute pressure''' (accounts for patient's perfusion status)
**Muscle: peroneus longus and brevis: foot plantarflexion
*Measure '''all compartments''' in the affected extremity (leg has 4: anterior, lateral, deep posterior, superficial posterior)
*Deep posterior
**Nerve: posterior tibial nerve: sensation of plantar aspect of foot
**Muscle: tibialis posterior/flexor hallucis longus/flexor digitorum longus: Pain with passive extension of the toes
*Superficial posterior
**Nerve: sural cutaneous nerve: sensation of lateral aspect of foot
**Muscle: gastrocnemius/soleus/plantaris: weakness of plantar flexion
[[File:lower_leg_compartment.png|thumb|Lower Leg Compartment]]


===Hand===
===Labs===
*Crush injury, with or with out associated fracture
*CK (elevated in [[rhabdomyolysis]])
*Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles
*BMP (monitor renal function, [[hyperkalemia]])
*Diagnosis
*Urinalysis (myoglobinuria)
**Clinical, not based on actual compartment pressure
**Pain
***Deep, constant, poorly localized, out of proportion to exam
**"Intrinsic minus" position at rest
***MCP joint extended with proximal IP joint slightly flexed
**Pain with passive stretch of involved compartmental muscles
***Interosseus: performed with MCP joint extended and PIP jionts fully flexed
***Thenar, hypothenar: performed by extension of MCP joint
**Tense swelling of affected compartment


===Forearm===
==Management==
[[File:Forearm_compartments.jpg|thumb|forearm compartments]]
===Immediate===
*Associated with supracondylar fracture (peds), distal radius fracture (adults)
*'''Remove all circumferential dressings, casts, and splints''' immediately
*Compartments
*Keep extremity '''at heart level''' (elevation may decrease arterial perfusion; dependent position worsens edema)
**Dorsal (highest risk)
*'''Avoid hypotension''' — maintain adequate perfusion pressure
**Volar
*'''IV fluid resuscitation''' if rhabdomyolysis
 
===Foot===
[[File:Compartments of the Foot.png|thumb|Compartments of the foot]]
*Number of compartments is controversial, but at least 4, up to 9
**Medial, lateral, central, interosseous, adductor
**Mechanism - crush injuries
**Other mechanisms - foot surgery, Lisfranc fracture, cast immobilization, prolonged extremity positioning, snake bites, severe ankle sprains with arterial disruption<ref>Haddad, Steven L. Managing risk: Compartment syndromes of the foot. AAOS, 2007. http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp</ref>
**5-17% of calcaneus fractures result in compartment syndrome
**Diagnosis
***Pain out of proprtion
***Pain worse with passive dorsiflexion (stretching intrinsic musculature of foot); concurrent metatarsal fracture cloud this finding
***Do not rely on absent pulse or complete anesthesia, which are late findings
***Measure absolute compartment pressures in [http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp insertion sites found here]
**Treatment
***Elevate extremity to level of heart (above the heart, and there will be reduction of O2 perfusion)
***SCDs may help decrease interstitial pressure, improve venous return/arterial flow
***Fasciotomy within 24 hrs of injury if pressures > 30 mmHg
 
===Lumbar Paraspinal===
*Compartment enclosed on the lateral, dorsal and ventral aspects by thoracolumbar fascia and medial aspect by spinous processes and interspinous ligaments
*Mechanisms
**Direct trauma
**Atraumatic mechanism (Heavy weight lifting)  
***Typically males in their 20's and 30's
**Recent surgery causing compromised blood supply
*Characteristics
**Pain of the low back refractory to analgesia
**Radiation of pain to the groin
**Tender and tense lumbar paraspinal muscles
**Loss of normal lumbar lordosis
**Worsening of pain with hip flexion
**Concurrent ileus in some cases
*Diagnosis
**Elevated CK
**Elevated compartment pressures
**Imaging not required
***If imaging is performed, MRI is the test of choice
***MRI will demonstrate enhancement of the paraspinal muscles on T2-weighted images
***CT is less helpful, but can exclude other causes of low-back pain such as fracture
*Treatment is with emergent fasciotomy and with fluid resuscitation for any concurrent rhabdomyolysis <ref>Alexander W. et al. Acute lumbar paraspinal compartment syndrome: a systematic review. ANZ Journal of Surgery. 2018; 88: 854-859.</ref>
[[File:MRI Lumbar Paraspinal Compartment Syndrome.png|thumb|Magnetic resonance imaging (T1-weighted with gadolinium) showing edema and high signal intensity (arrows) in the region of the left multifidus and longissimus muscles.]] 
 
===Other===
*Thigh (quadriceps compartment)
[[File:Compartments_of_the_Thigh.png|thumb|Compartments of the thigh]]
*Buttock (gluteal compartment)
*Arm (deltoid, biceps compartments)
*Abdominal
 
==Differential Diagnosis==
{{Extremity trauma DDX}}
{{Calf pain DDX}}
 
==Evaluation==
===Work-Up===
*X-ray to evaluate for fracture
*[[Compartment pressure measurement]] (take serial measurements if needed)
*Total CK ([[rhabdomyolysis]])
*Chemistry ([[hyperkalemia]])


{{Compartment Pressure Interpretation}}
===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


==Management==
===Post-Fasciotomy Monitoring===
#Fasciotomy
*Serial CK, renal function, electrolytes
#*Perform as soon as diagnosis is made by history/physical or by measurement
*Monitor for reperfusion injury ([[hyperkalemia]], [[metabolic acidosis]], [[rhabdomyolysis]])
#*Permanent damage results from >8hr of ischemia
*Broad-spectrum antibiotics if contaminated wound
#*Refer here for technique: http://www.wheelessonline.com/ortho/12806
#Support blood pressure in hypotensive patient
#Place affected limb at the level of the heart or slightly dependent
#AVOID ice (will further compromise microcirculation)
#Bivalve or remove cast if present
#Adequate analgesia
#Management for associated [[rhabdomyolysis]] if present


==Disposition==
==Disposition==
*Admit
*'''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==
==See Also==
*[[Compartment Pressure Measurement]]
*[[Burns]]
*[[Rhabdomyolysis]]
*[[Rhabdomyolysis]]
*[[Fractures (Main)]]
*[[Fractures]]
*[[Abdominal compartment syndrome]]
*[[Crush syndrome]]
 
*[[Snakebite]]
==External Links==


==References==
==References==
<references/>
<references/>
[[Category:Orthopedics]] [[Category:Trauma]]
*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]]

Revision as of 19:45, 21 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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