Compartment syndrome: Difference between revisions

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==Background==
==Background==
*Consider whenever pain and paresthesia occur in an extremity after a fracture
*Increased pressure within a closed fascial compartment compromising perfusion to muscles and nerves
*Immediate threat is viability of nerve and muscle
*'''Surgical emergency''' — irreversible damage begins within '''6-8 hours''' of ischemia
**Later threat is infection, gangrene, rhabdo, and renal failure
*Most common location: anterior compartment of the leg (tibia fractures)
*Pathophysiology
**Tissue perfusion is difference between diastolic BP and compartment pressure
***As compartment pressure increases, tissue perfusion decreases
 
==Etiology==
*Most commonly caused by tibia fracture (anterior compartment)
*Usually develops soon after significant trauma
**May be delayed up to 48hr after the event
*Causes:
*Causes:
#Orthopedic
**Fractures (most common — especially tibia, forearm, supracondylar humerus in children)
##Tibial fractures
**Crush injuries, reperfusion injury after vascular repair
##Forearm fractures
**Burns (circumferential), tight casts/splints/dressings
#Vascular
**Hemorrhage (anticoagulation), [[rhabdomyolysis]]
##Ischemic-reperfusion injury
**Envenomation ([[snakebite]])
##Hemorrhage
**IV/IO infiltration
#Iatrogenic
*Normal tissue pressure: 0-8 mmHg
##Vascular puncture in anticoagulated patients
*Ischemia begins when compartment pressure exceeds capillary perfusion pressure
##IV/intra-arterial drug injection
##Constrictive casts
#Soft tissue injury
##Prolonged limb compression
##Crush injury
##Burns
 
 
==Diagnosis==
===Clinical Findings===
*Pain
**Severe, out of proportion to physical findings
**Worse w/ passive movement (this extends the muscle -> incr in volume -> incr pressure)
*Paresthesia
**Occurs in sensory distribution of affected nerve
*Compartment is swollen, firm, tender w/ squeezing
*5 P's (pain, paresthesias, pallor, pulselessness, paralysis)
**Classic signs of disruption in arterial flow, not of compartment syndrome
***Only found once arterial flow has stopped (very late finding)
===Compartment Pressure===
*Normal is <10
*Pressures <30 can be tolerated w/o significant damage
*Exact level of pressure elevation that causes cell death is unclear
*"Delta Pressure" may be better predictor than absolute pressure value
**Diastolic BP - intracompartmental pressure
***Once this value is <30 compartment syndrome is likely
 
 
==Work-Up==
*Compartment pressure (take serial measurements if needed)
*Total CK, UA (rhabdo)
*Chemistry (hyperkalemia)


==Specific Syndromes==
==Clinical Features==
===Lower Leg===
*The 6 P's (pain is earliest and most reliable; pulselessness is latest):
*Compartments
**Pain — out of proportion to exam (most sensitive early finding)
#Anterior
**Pain with passive stretch of muscles in affected compartment (most sensitive exam finding)
##Nerve: Deep fibular (peroneal)
**Pressure — tense, firm compartment on palpation
###Sensation of 1st webspace
**Paresthesias — indicates nerve ischemia
##Muscle: tibialis anterior
**Paralysis — late finding; indicates significant ischemia
###Weakness of foot dorsiflexion
**Pulselessness — very late finding; presence of pulses does NOT exclude compartment syndrome
#Lateral
*Key pearls:
##Nerve: Superficial fibular (peroneal) nerve
**Increasing analgesic requirements should raise suspicion
###Sensation of lateral aspect of lower leg, dorsum of foot
**Normal pulses and capillary refill do NOT rule out compartment syndrome
##Muscle: Peroneus
**'''Obtunded, intubated, or pediatric patients''' cannot report pain — maintain '''high index of suspicion'''
###Weakness of foot plantarflexion
#Deep posterior
##Nerve: Posterior tibial nerve
###Sensation of plantar aspect of foot
##Muscle: flexor hallucis/digotirum longus
###Pain with passive extension of the toes
#Superficial posterior
##Nerve: Sural cutaneous nerve
###Sensation of lateral aspect of foot
##Muscle: Gastrocnemius
###Weakness of plantarflexion


===Hand===
==Differential Diagnosis==
*Crush injury, w/ or w/o associated fracture
*[[Deep vein thrombosis]]
*Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles
*[[Cellulitis]] / [[necrotizing fasciitis]]
*Diagnosis
*Fracture pain
**Clinical, not based on actual compartment pressure
*Peripheral vascular injury
**Pain
*Neuropraxia
***Deep, constant, poorly localized, out of proportion to exam
*[[Rhabdomyolysis]] without compartment syndrome
**"Intrinsic minus" position at rest
*Acute [[arterial occlusion]]
***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===
==Evaluation==
*Compartments
===Clinical Diagnosis===
**Dorsal
*Compartment syndrome is primarily a CLINICAL diagnosis
**Volar
*Serial examinations are essential
**Mobile wad
*'''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)


===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


*Supracondylar humerus fracture (children)
===Fasciotomy===
*Distal radius fractures (adults)
*Definitive treatment — emergent surgical consultation
*Deep volar
*Four-compartment fasciotomy for lower leg
**At highest risk for comp sy
*Delay >6-8 hours: significantly increased risk of permanent neuromuscular damage, amputation
**Contains the digital flexors
*'''Do NOT delay for imaging''' if diagnosis is clinically apparent
***Includes flexor digitorum profundus (responsible for distal interphalangeal joint flexion) and the flexor pollicis longus (responsible for interphalangeal joint flexion of the thumb)
*Wound typically left open with delayed primary closure or skin grafting at 48-72 hours
**Decreased wrist extension
*Superficial volar
*Dorsal
**Contains the digital extensors
*Lateral


===Post-Fasciotomy Monitoring===
*Serial CK, renal function, electrolytes
*Monitor for reperfusion injury ([[hyperkalemia]], [[metabolic acidosis]], [[rhabdomyolysis]])
*Broad-spectrum antibiotics if contaminated wound


==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


==Treatment==
==See Also==
#Fasciotomy
*[[Rhabdomyolysis]]
##Perform as soon as diagnosis is made by history/physical or by measurement
*[[Fractures]]
##Permanent damage results from >8hr of ischemia
*[[Crush syndrome]]
#Support the blood pressure in the hypotensive pt
*[[Snakebite]]
#Place affected limb at the level of the heart or slightly dependent
#AVOID ice (will further compromise microcirculation)
#Bivalve or remove cast if present


==Source==
==References==
*Tintinalli
<references/>
*Rosen's
*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:Ortho]]
[[Category:Orthopedics]]
[[Category:Trauma]]

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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