Compartment syndrome: Difference between revisions
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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
*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


{{Compartment Syndrome Indications}}
==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==
*[[Deep vein thrombosis]]
*[[Cellulitis]] / [[necrotizing fasciitis]]
*Fracture pain
*Peripheral vascular injury
*Neuropraxia
*[[Rhabdomyolysis]] without compartment syndrome
*Acute [[arterial occlusion]]


===Pathophysiology===
==Evaluation==
*Tissue perfusion is difference between diastolic BP and compartment pressure
===Clinical Diagnosis===
**As compartment pressure increases, tissue perfusion decreases
*Compartment syndrome is primarily a CLINICAL diagnosis
*Serial examinations are essential
*'''Do not delay fasciotomy for pressure measurement''' if clinical picture is clear


===Etiologies===
===Compartment Pressure Measurement===
*Orthopedic
*Indicated when clinical exam is unreliable (obtunded, pediatric, equivocal exam)
**[[Tibial fracture]]
*Methods: Stryker needle (most common in ED), arterial line transducer
**[[Forearm fracture]]
*Absolute pressure >30 mmHg: concerning
*Vascular
*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>
**Ischemic-reperfusion injury
*'''Delta pressure is more reliable than absolute pressure''' (accounts for patient's perfusion status)
**Hemorrhage
*Measure all compartments in the affected extremity (leg has 4: anterior, lateral, deep posterior, superficial posterior)
*Iatrogenic
**Vascular puncture in anticoagulated patients
**IV/intra-arterial drug injection
**Constrictive casts
*Soft tissue injury
**Prolonged limb compression
**[[Crush injury]]
**[[Burn]]
**[[Snake bite]]


== Clinical Features ==
===Labs===
===General Symptoms===
*CK (elevated in [[rhabdomyolysis]])
*Compartment is swollen, firm, tender w/ squeezing
*BMP (monitor renal function, [[hyperkalemia]])
*Usually develops soon after significant trauma
*Urinalysis (myoglobinuria)
**May be delayed up to 48hr after the event


====5 P's====
==Management==
*Classic signs of disruption in arterial flow, not of compartment syndrome
===Immediate===
**Only found once arterial flow has stopped (very late finding)
*'''Remove all circumferential dressings, casts, and splints''' immediately
#Pain
*Keep extremity at heart level (elevation may decrease arterial perfusion; dependent position worsens edema)
#*Severe, out of proportion to physical findings
*Avoid hypotension — maintain adequate perfusion pressure
#*Worse w/ passive movement (muscle extension > increased volume > increased pressure)
*IV fluid resuscitation if rhabdomyolysis
#*Often the presenting symptom.
#Paresthesia
#*Occurs in sensory distribution of affected nerve
#Pallor
#Paralysis: late finding
#Pulselessness: late finding


=== Lower Leg Specific Syndromes===  
===Fasciotomy===
*Anterior
*Definitive treatment — emergent surgical consultation
**Nerve: deep fibular (peroneal): sensation of 1st webspace
*Four-compartment fasciotomy for lower leg
**Muscle: tibialis anterior: foot/ankle dorsiflexion
*Delay >6-8 hours: significantly increased risk of permanent neuromuscular damage, amputation
*Lateral
*'''Do NOT delay for imaging''' if diagnosis is clinically apparent
**Nerve: superficial fibular (peroneal) nerve: sensation of lateral aspect of lower leg, dorsum of foot
*Wound typically left open with delayed primary closure or skin grafting at 48-72 hours
**Muscle: peroneus longus and brevis: foot plantarflexion
*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 ===
===Post-Fasciotomy Monitoring===
*Crush injury, w/ or w/o associated fracture
*Serial CK, renal function, electrolytes
*Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles
*Monitor for reperfusion injury ([[hyperkalemia]], [[metabolic acidosis]], [[rhabdomyolysis]])
*Diagnosis
*Broad-spectrum antibiotics if contaminated wound
**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 w/ proximal IP joint slightly flexed
**Pain w/ passive stretch of involved compartmental muscles
***Interosseus: performed w/ MCP joint extended and PIP jionts fully flexed
***Thenar, hypothenar: performed by extension of MCP joint
**Tense swelling of affected compartment


=== Forearm ===
==Disposition==
[[File:Forearm_compartments.jpg|thumb|forearm compartments]]
*All suspected cases require admission and emergent orthopedic/surgical consultation
*Associated w/ supracondylar fx (peds), distal radius fx (adults)
*ICU if [[rhabdomyolysis]] or hemodynamic instability
*Compartments
*Missed compartment syndrome is a significant medicolegal risk
**Dorsal (highest risk)
**Volar
 
=== 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 fx, 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 fx 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
 
=== 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==
{{Calf pain DDX}}
 
== Diagnosis ==
=== Work-Up ===
*xray to rule out fracture
*Compartment pressure (see below; take serial measurements if needed)
*Total CK, UA ([[rhabdo]])
*Chemistry ([[hyperkalemia]])
 
===[[Compartment Pressure Measurement|Measure Compartment Pressure]]===
{{Compartment Pressure Interpretation}}
 
== Treatment ==
#Fasciotomy
#*Perform as soon as diagnosis is made by history/physical or by measurement
#*Permanent damage results from >8hr of ischemia
#Support blood pressure in hypotensive pt
#Place affected limb at the level of the heart or slightly dependent
#AVOID ice (will further compromise microcirculation)
#Bivalve or remove cast if present


==See Also==
==See Also==
*[[Compartment Syndrome]]
*[[Compartment Pressure Measurement]]
*[[Burns]]
*[[Rhabdomyolysis]]
*[[Rhabdomyolysis]]
*[[Fractures (Main)]]
*[[Fractures]]
*[[Crush syndrome]]
*[[Snakebite]]


== References ==
==References==
<references/>
<references/>
[[Category:Ortho]] [[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]]

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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