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Emergency And Acute Medicine – Compartment Syndrome
Description
Compartment syndrome is a condition caused by elevated tissue pressure within a closed fascial space, leading to compromised capillary blood flow and subsequent ischemia. Normal tissue pressure is less than 10 mm Hg. Capillary perfusion becomes impaired at pressures greater than 20 mm Hg, and irreversible ischemic necrosis of muscle and nerve tissue may occur at pressures exceeding 30 mm Hg. When distal pulses are diminished on examination, significant muscle necrosis is usually already present. Although the four compartments of the lower leg are most commonly affected, compartment syndrome may also occur in the arm, forearm, hand, foot, thigh, buttocks, or shoulder.
Etiology
Compartment pressure may rise due to either a decrease in compartment size or an increase in compartment contents. Reduced compartment size occurs with circumferential casts, burn eschar, or use of military antishock trousers. Increased compartment contents result from edema or hematoma related to fractures, blunt trauma, overexertion, contrast extravasation, injection of recreational drugs, reperfusion after ischemia, or prolonged limb compression during immobilization.
Clinical Alert
The affected extremity should be maintained at the level of the heart to optimize arterial inflow without impairing venous return. Ice should not be applied when compartment syndrome is suspected, as it may further compromise microcirculation.
Clinical Presentation
Patients typically report severe, constant pain over the involved compartment that is out of proportion to the apparent injury. Pain worsens with active muscle contraction and passive stretching. Additional findings include muscle weakness and sensory changes such as hypesthesia. The classic “six Ps” include pain, pressure, paresis, paresthesia, pallor, and pulses present until late in the disease process.
Physical Examination
Examination reveals tense, tender muscle compartments. Motor strength and neurologic function should be carefully assessed and documented. Pulses may remain intact early and should not be used to exclude the diagnosis.
Diagnostic Evaluation
Plain radiographs should be obtained when fracture is suspected. Definitive diagnosis is made by measuring intracompartmental pressures, commonly using a compartment pressure monitoring system with an 18-gauge needle or continuous pressure monitoring catheter. After sterile preparation, the needle is advanced until the fascia is penetrated, followed by injection of a small saline volume to clear the lumen. Pressure readings should transiently rise with muscle compression or passive stretch and return to baseline when the maneuver is stopped, confirming correct placement.
Differential Diagnosis
Conditions that may mimic compartment syndrome include chronic exertional compartment syndrome, fascial hernia, stress fracture, arterial occlusion, neurapraxia, deep venous thrombosis, cellulitis, osteomyelitis, tenosynovitis, and synovitis.
Initial Stabilization
Any constrictive dressings or casts should be immediately loosened, univalved, and spread, with cast padding cut down to the skin. The limb should remain at heart level while awaiting definitive management.
Emergency Department Management
Acute compartment syndrome is a surgical emergency. Fasciotomy is the definitive treatment and is strongly indicated for compartment pressures exceeding 30–40 mm Hg. Early orthopedic or surgical consultation is essential.
Medications
Pharmacologic therapy does not treat the underlying pathology. Steroids and vasodilators are ineffective. Intravenous opioid analgesics may provide limited pain relief but are often insufficient, as definitive pain control usually requires surgical decompression. Oral analgesics and nonsteroidal anti-inflammatory drugs offer little acute benefit.
Disposition And Follow-Up
Patients with compartment pressures greater than 30 mm Hg require emergent surgical consultation and admission. Those with pressures between 20 and 30 mm Hg should be admitted for observation and surgical evaluation. Pressures between 15 and 20 mm Hg warrant serial measurements, and admission is recommended if reliable follow-up cannot be ensured. Patients with pressures below 10–15 mm Hg may be discharged with strict return precautions for worsening pain, swelling, or neurologic symptoms.
Referral Considerations
Suspected chronic compartment syndrome requires prompt orthopedic referral, ideally with direct communication to convey clinical concern.
Clinical Pearls And Pitfalls
Compartment pressures must be measured promptly or the patient transferred to a facility with this capability. Careful technique is required to avoid iatrogenic injury during pressure measurement. Concomitant rhabdomyolysis should always be considered in crush or prolonged compression injuries.
Description
Compartment syndrome is a condition caused by elevated tissue pressure within a closed fascial space, leading to compromised capillary blood flow and subsequent ischemia. Normal tissue pressure is less than 10 mm Hg. Capillary perfusion becomes impaired at pressures greater than 20 mm Hg, and irreversible ischemic necrosis of muscle and nerve tissue may occur at pressures exceeding 30 mm Hg. When distal pulses are diminished on examination, significant muscle necrosis is usually already present. Although the four compartments of the lower leg are most commonly affected, compartment syndrome may also occur in the arm, forearm, hand, foot, thigh, buttocks, or shoulder.
Etiology
Compartment pressure may rise due to either a decrease in compartment size or an increase in compartment contents. Reduced compartment size occurs with circumferential casts, burn eschar, or use of military antishock trousers. Increased compartment contents result from edema or hematoma related to fractures, blunt trauma, overexertion, contrast extravasation, injection of recreational drugs, reperfusion after ischemia, or prolonged limb compression during immobilization.
Clinical Alert
The affected extremity should be maintained at the level of the heart to optimize arterial inflow without impairing venous return. Ice should not be applied when compartment syndrome is suspected, as it may further compromise microcirculation.
Clinical Presentation
Patients typically report severe, constant pain over the involved compartment that is out of proportion to the apparent injury. Pain worsens with active muscle contraction and passive stretching. Additional findings include muscle weakness and sensory changes such as hypesthesia. The classic “six Ps” include pain, pressure, paresis, paresthesia, pallor, and pulses present until late in the disease process.
Physical Examination
Examination reveals tense, tender muscle compartments. Motor strength and neurologic function should be carefully assessed and documented. Pulses may remain intact early and should not be used to exclude the diagnosis.
Diagnostic Evaluation
Plain radiographs should be obtained when fracture is suspected. Definitive diagnosis is made by measuring intracompartmental pressures, commonly using a compartment pressure monitoring system with an 18-gauge needle or continuous pressure monitoring catheter. After sterile preparation, the needle is advanced until the fascia is penetrated, followed by injection of a small saline volume to clear the lumen. Pressure readings should transiently rise with muscle compression or passive stretch and return to baseline when the maneuver is stopped, confirming correct placement.
Differential Diagnosis
Conditions that may mimic compartment syndrome include chronic exertional compartment syndrome, fascial hernia, stress fracture, arterial occlusion, neurapraxia, deep venous thrombosis, cellulitis, osteomyelitis, tenosynovitis, and synovitis.
Initial Stabilization
Any constrictive dressings or casts should be immediately loosened, univalved, and spread, with cast padding cut down to the skin. The limb should remain at heart level while awaiting definitive management.
Emergency Department Management
Acute compartment syndrome is a surgical emergency. Fasciotomy is the definitive treatment and is strongly indicated for compartment pressures exceeding 30–40 mm Hg. Early orthopedic or surgical consultation is essential.
Medications
Pharmacologic therapy does not treat the underlying pathology. Steroids and vasodilators are ineffective. Intravenous opioid analgesics may provide limited pain relief but are often insufficient, as definitive pain control usually requires surgical decompression. Oral analgesics and nonsteroidal anti-inflammatory drugs offer little acute benefit.
Disposition And Follow-Up
Patients with compartment pressures greater than 30 mm Hg require emergent surgical consultation and admission. Those with pressures between 20 and 30 mm Hg should be admitted for observation and surgical evaluation. Pressures between 15 and 20 mm Hg warrant serial measurements, and admission is recommended if reliable follow-up cannot be ensured. Patients with pressures below 10–15 mm Hg may be discharged with strict return precautions for worsening pain, swelling, or neurologic symptoms.
Referral Considerations
Suspected chronic compartment syndrome requires prompt orthopedic referral, ideally with direct communication to convey clinical concern.
Clinical Pearls And Pitfalls
Compartment pressures must be measured promptly or the patient transferred to a facility with this capability. Careful technique is required to avoid iatrogenic injury during pressure measurement. Concomitant rhabdomyolysis should always be considered in crush or prolonged compression injuries.
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