British Journal of Anaesthesia 102 (1): 3–11 (2009)

doi:10.1093/bja/aen330 Advance Access publication November 19, 2008

REVIEW ARTICLES
Acute compartment syndrome of the lower limb and the effect
of postoperative analgesia on diagnosis†
G. J. Mar*, M. J. Barrington and B. R. McGuirk

Department of Anaesthesia, St Vincent’s Hospital, Melbourne, PO Box 2900, Fitzroy,

3065 VIC, Australia
*Corresponding author. E-mail: gjpmar@yahoo.com.au
Acute compartment syndrome can cause significant disability if not treated early, but the diag-

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nosis is challenging. This systematic review examines whether modern acute pain management
techniques contribute to delayed diagnosis. A total of 28 case reports and case series were
identified which referred to the influence of analgesic technique on the diagnosis of compart-
ment syndrome, of which 23 discussed epidural analgesia. In 32 of 35 patients, classic signs and
symptoms of compartment syndrome were present in the presence of epidural analgesia,
including 18 patients with documented breakthrough pain. There were no randomized con-
trolled trials or outcome-based comparative trials available to include in the review. Pain is
often described as the cardinal symptom of compartment syndrome, but many authors con-
sider it unreliable. Physical examination is also unreliable for diagnosis. There is no convincing
evidence that patient-controlled analgesia opioids or regional analgesia delay the diagnosis of
compartment syndrome provided patients are adequately monitored. Regardless of the type of
analgesia used, a high index of clinical suspicion, ongoing assessment of patients, and compart-
ment pressure measurement are essential for early diagnosis.
Br J Anaesth 2009; 102: 3–11
Keywords: anaesthetic techniques, regional; analgesia, postoperative; complications,
compartment syndrome; complications, trauma; position, lithotomy

Compartment syndrome is a condition in which increased be a cardinal feature of compartment syndrome and it has
pressure within a closed compartment compromises the cir- been claimed that analgesia may delay its diagnosis resulting
culation and function of the tissues within that space.65 It in a poor patient outcome.
occurs most commonly in an osseofascial compartment of The primary objective of this review was to undertake a
the leg or forearm, but it may occur in the upper arm, thigh, systematic review of articles relating postoperative analge-
foot, buttock, hand, and abdomen. The most common cause sia to a delay in diagnosis of compartment syndrome. In
of compartment syndrome is trauma, usually after a frac- addition, a literature review was performed to detail the
ture.11 In an audit, 4.3% of all patients with tibial shaft frac- pathophysiology, clinical presentation, and role of compart-
tures, 3.1% of diaphyseal fractures of the forearm, and ment pressure manometry. The focus was on compartment
0.25% fractures of the distal radius developed acute compart- syndrome of the lower limbs after trauma and surgery.
ment syndrome.36 It is seen more commonly in patients ,35
yr of age34 and in male patients.36 42 Compartment syndrome
also occurs in the context of reperfusion, ischaemia, burns, Clinical presentation, diagnosis, and
and poor positioning for prolonged surgical procedures (par-
monitoring
ticularly lithotomy position)55 and in drug-affected individ-
uals (Table 1).28 The incidence of compartment syndrome is The underlying pathophysiology of acute compartment syn-
up to 20% in acutely ischaemic limbs that have been revas- drome is an ischaemia–reperfusion–ischaemia cycle.
cularized.7 Acute compartment syndrome requires prompt Ischaemia can be precipitated by remote perfusion failure
diagnosis and management. Delays in treatment can result in †
Presented as a poster at the European Society of Regional
significant disability including neurological deficit, muscle
Anaesthesia and Pain Therapy, XXVII Annual Congress, Genoa,
necrosis, amputation, and death. The diagnosis requires a Italy, in September 2008 and published in part as an abstract in Reg
high index of suspicion and is challenging. Pain is thought to Anesth Pain Med 2008; 33: e185.

# The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
 Mar et al.

Table 1 Common aetiology of compartment syndrome compartmental pressure of 30 mm Hg.20 In a clinical

Orthopaedic Fractures and fracture surgery setting, it is not possible to pinpoint the precise time com-
Vascular Arterial and venous injuries partment syndrome develops. The incidence of compli-
Reperfusion injury cations is related to the time from diagnosis to
Haemorrhage
Soft tissue Crush injury fasciotomy.37 42 Catastrophic outcomes were inevitable if
Burns fasciotomies were delayed for more than 12 h, whereas a
Prolonged limb compression full recovery was achieved if decompression was per-
Iatrogenic Arterial/venous puncture in anticoagulated patients
Casts and circular dressings formed within 6 h of making a diagnosis.11 In addition to
Pulsatile irrigation poor clinical outcome, a delayed diagnosis has medico-
Surgical positioning—especially prolonged lithotomy position legal ramifications. In a review of closed claims in a state
Pneumatic antishock garment
Other Snakebite in the USA spanning 23 yr, out of 1515 cases involving
Muscle overuse orthopaedic surgeons, 19 claims related to compartment
syndrome in 16 patients. Nine cases were resolved in favour
of the patient and seven in favour of the surgeon with poor
(vascular obstruction or trauma, systemic hypotension) or surgeon–patient communication being a reason for com-

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by increased resistance to flow within the compartment pensation in six instances. Defence was always successful
itself.31 The ischaemia results in tissue membrane damage when a fasciotomy was performed within 8 h of the first
and leakage of fluid through capillary and muscle mem- presenting symptom.5 Patients at risk of compartment syn-
branes. With arterial reperfusion, the damaged membrane drome are often poorly assessed. In a retrospective study of
continues to leak, increasing oedema formation and the preoperative medical records of 30 consecutive patients
pressure in the closed compartment. The clinical signs and who underwent fasciotomies for compartment syndrome,
symptoms of acute compartment syndrome are known to be documentation was inadequate for 21 (70%) patients.9
unreliable.1 11 27 28 35 66 The symptoms of compartment syn-
drome are severe pain and paraesthesia. This is difficult to
assess at the extremes of age or in those with central Compartment pressure monitoring
nervous system (CNS) compromise.28 CNS compromise can Compartmental pressure measurement is recommended in
be a particular issue after general anaesthesia and in sedated high-risk patients as an adjunct to clinical diagnosis27 35
patients in an intensive care setting. Difficulties with seda- except where the diagnosis is obvious.28 Normal pressure
tion or pain management may be the only clinical indicator in the muscle compartment is below 10– 12 mm Hg.65
of compartment syndrome in this group.16 However, pain The compartmental perfusion pressure is the difference
may be an unreliable symptom as it is subjective and vari- between the diastolic arterial pressure and the compart-
able. It may be absent in established acute compartment mental pressure. The diagnostic pressure difference in one
syndrome associated with nerve injury, or minimal in deep study was 21 mm Hg.27 Absolute compartment pressures
posterior compartment syndrome.35 The signs of compart- of 4532 and 30 mm Hg40 have been suggested as
ment syndrome are tense, swollen compartments, pain on thresholds for compartment syndrome. Needle manometers
passive stretching of the muscle, and sensory loss. are commonly utilized for compartment pressure measure-
Pulselessness is not common and generally implies a late ment. They are cheap and easy to use, but have been
stage.62 In a review examining the clinical signs and symp- shown to have inaccuracies and cannot be used continu-
toms of compartment syndrome, the false-positive rate was ously.11 Catheter techniques are effective for continuous
shown to be high in relation to the true-positive rate.66 That compartmental pressure measurement but require accurate
is, clinical findings of compartment syndrome were more placement of the external transducer, have more complex
likely to be present in patients who do not have compart-
ment syndrome than in those who do. A lack of clinical
signs and symptoms was more helpful in excluding the
diagnosis than was the presence of findings for confirming Anterior
compartment syndrome. In a prospective study using a pre-
determined screening protocol for lower extremity compart- Deep
ment syndrome in critically ill trauma patients, physical posterior
examination was considered inaccurate for diagnosis. On
completion of the study, it was decided not to use physical
examination as part of the screening protocol.27
Lateral
Compartment syndrome must be treated urgently as the
extent of injury is mainly determined by the duration of Superficial
ischaemia and the pressure in the osseofascial compart- posterior

ment. In a canine model of compartment syndrome, sig-

nificant muscle necrosis occurs after 8 h with a Fig 1 Osseofascial compartments of the calf.

4
 Acute compartment syndrome and the effect of postoperative analgesia

equipment, and fragments of tissue or clots can obstruct Systematic review

the tip affecting accuracy. In Figure 1, the position of the A systematic review of articles relating postoperative
various osseofascial compartments of the calf and the analgesia to the diagnosis of acute compartment syndrome
approach when inserting a needle manometer are demon- of the limb was conducted. The Pubmed, MEDLINE and
strated. All compartments in a limb suspected of having EMBASE databases, Cochrane Library, and Google
compartment syndrome should be measured.28 The com- Scholar were searched from 1986 to present. We used a
partment with the highest initial pressure reading should combination of search terms: compartment syndrome/epi-
be used for continuous pressure measurement.11 It should dural/extradural/analgesia/an(a)esthesia/an(a)esthetic/nerve
be noted that neuromuscular damage is caused by ischae- block/regional/diagnosis/surgery. The search was restricted
mia rather than elevated pressure alone. to articles published in the English language and letters of
correspondence and surveys were excluded. The reference
Other monitors and investigations sections of relevant articles were hand searched for further
publications. Reports were included if they related post-
Near-infrared spectroscopy (NIRS) measures tissue oxy- operative analgesia to the management and diagnosis of
genation and shows promise in monitoring for compart- acute compartment syndrome. Two case reports described

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mental ischaemia. It has an advantage over needle and the same patient, so only the earlier report was included.45
catheter techniques in that it measures tissue hypoxia 46
The reports were examined by all the authors.
directly using a principle similar to pulse oximetry.14 A total of 28 case reports (n¼20) and case series (n¼8)
Muscle oxyhaemoglobin (StO2) levels measured by NIRS were identified which referred to the influence of analgesic
strongly reflect compartment pressure, perfusion pressure, technique on the diagnosis of compartment syndrome.
and loss of myoneural function. StO2 was a more consistent These techniques were patient-controlled analgesia (PCA;
predictor of neuromuscular dysfunction than compartment n¼3), peripheral nerve block (PNB; n¼2), and epidural
perfusion pressure.13 It is non-invasive and can be used analgesia (n¼23), respectively. A large audit of epidural
continuously, thus allowing duration of ischaemia to be use in the UK and Ireland also analysed the diagnosis of
measured. Unfortunately, the equipment is expensive and acute compartment syndrome in children.30 There were
only measures to a limited depth, not reaching the deep no randomized controlled trials or any other outcome-
posterior compartment of the calf. Another technique based comparative trials to include. All the evidence is
under evaluation is pulsed phase-locked loop ultrasound, Level 3.19
which can analyse fascial displacement waveforms which
correspond to arterial pulsations and change with increased
compartmental pressure.67 MRI can show the tissue
changes in established compartment syndrome but is not Analgesia and diagnosis of compartment syndrome
good for diagnosing an evolving compartment syndrome.28 PCA was implicated in a delay in the diagnosis of acute
Its use is limited by the time taken to perform the scan, compartment syndrome of the lower limb in three reports
potentially delaying management. Serum creatine phos- describing six male patients with tibial fractures. Two case
phokinase (CK), which reflects muscle necrosis, has been reports detail patients with traumatic mid-shaft tibial frac-
used as an indicator of compartment syndrome. tures who had PCA morphine for analgesia after intrame-
Significantly elevated CK levels may be useful in diagno- dullary nailing (90 mg over 24 h and 131 mg over 36 h,
sis where the clinical picture is not obvious and compart- respectively).21 46 The first patient complained of reduced
mental pressure measurement devices are not available.47 sensation and foot movement prompting a diagnosis of
Monitoring may increase clinical awareness and aid diag- compartment syndrome. The other patient had no pain
nosis in the presence of equivocal clinical findings.11 In a observations from 6 h post-surgery and compartment syn-
retrospective review of the use of compartment pressure drome was an incidental finding when the patient returned
monitoring in tibial diaphyseal fractures, the average delay to theatre for scheduled wound closure 36 h after the orig-
from fracture manipulation to fasciotomy was 7 h in the inal procedure. A case series of four patients who had
monitored group and 24 h in the non-monitored group. The compartment syndrome after tibial fractures where it was
complication rate in those without monitoring (10/11) was thought that PCA opioids delayed the diagnosis has been
higher compared with those in the monitored group (0/ reported.50 The patients in these reports had doses of 0.5–
12).35 Lack of compartment pressure monitoring and 1 mg h21 of PCA morphine. These are small doses,64
inadequate assessment and observation are the most suggesting that the patients did not have severe pain. The
common factors associated with a missed diagnosis.63 Most case reports provide limited detail on the clinical care pro-
surgeons accept that compartmental pressure measurement vided to these patients in the lead up to the diagnosis of
is important for the diagnosis of compartment syndrome,28 compartment syndrome. Other clinical features like para-
and invasive arterial pressure transducers are widely avail- esthesia and swelling were not mentioned. Two authors
able and can be attached to a saline-filled catheter placed in recommend avoiding PCA in favour of intermittent i.m.
a compartment as a manometer. morphine injections.21 46 The preference for this modality

5
 Mar et al.

was that it facilitates nursing contact with patients who syndrome. Reference to the signs and symptoms of com-
can be avoided with PCA. partment syndrome should be in the immediate vicinity of
We did not find any case reports suggesting PNB any patient at risk. This could be on a designated ortho-
delayed the diagnosis of upper limb compartment syn- paedic observations chart alongside pain (including
drome. In a literature review to establish whether a analgesic requirements), neurovascular, and vital signs.
femoral nerve block may mask the signs and symptoms of Risk assessment tools have been described which may aid
thigh compartment syndrome, there was no evidence of an monitoring patients at high risk of developing acute com-
association between a femoral nerve block and a delayed partment syndrome.27 Written protocols detailing appropri-
or missed diagnosis.25 However, a postoperative single ate care including the management of adverse events and
shot 3-in-1 block using bupivacaine 0.5% may have led to triggers for medical review are important.
a delayed diagnosis of calf compartment syndrome after Pain may be an unreliable symptom as it is subjective
intramedullary nailing of a tibial fracture.23 However, and variable. However, in many of the case reports
femoral nerve block would not have completely removed reviewed, pain was present but compartment syndrome not
the pain associated with a tibial injury as much of the pain considered for a period of time.3 10 15 18 24 43 57 59
will have been in the sciatic nerve distribution. In a report Increasing demands for analgesia should trigger clinical

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of foot compartment syndrome after a forefoot arthro- review because these events have preceded neurovascular
plasty, the author suggests an ankle block delayed the changes by 7.3 h.1 PCA and continuous infusions of local
diagnosis, yet pain was a significant clinical feature in the anaesthetics may aid the diagnosis of compartment syn-
postoperative period.44 drome when patients analgesic requirements are observed
Many authors state that the presence of epidural analge- appropriately. The view that analgesia should be with-
sia did not contribute to a delay in the diagnosis of com- drawn or an inferior mode of analgesia be used to facili-
partment syndrome.2 10 15 22 24 30 38 58 65 There were four tate diagnosis of compartment syndrome should be
cases of compartment syndrome in a large multicentre pro- discouraged. Withholding analgesia to patients with acute
spective audit of the use of epidural analgesia in children abdominal pain for fear of masking pathology was once
in the UK and Ireland. Each case was diagnosed without common clinical practice, but now it is considered safe
delay, despite highly effective analgesia in two patients and humane to administer narcotic analgesia to patients
and less effective analgesia in the others.30 Classic signs presenting with acute abdominal pain.33 Analgesia is
and symptoms were present when compartment syndrome required after trauma and surgery on humane grounds
developed in 32 of 35 patients discussed in the case alone and pain management is a core responsibility of our
reports (n¼16) and series (n¼7) relating to epidural specialty.
analgesia. This includes 18 patients with documented There is a lack of appreciation by some authors of the
breakthrough pain (Table 2). In contrast, there was a delay importance of the pharmacology of epidural analgesia in
in diagnosis in three patients with dense bilateral motor the clinical presentation. For example, a report of four
blocks.26 57 60 In one report,60 the patient had ‘complete patients who developed gluteal compartment syndrome in
anaesthesia’ from the waist down in the postoperative the context of postoperative epidural analgesia does not
period, implying a complete motor and sensory block, and describe the clinical examination or drugs used.29 The
in the others,26 57 the patients had dense motor and fourth patient in this series was noted to have complete
sensory blocks for more than 18 h after operation. These ankle paralysis 4 h after cessation of 43 h of continuous
patients did not have breakthrough pain due to their dense epidural analgesia. This suggests that either it was a new
blocks, which is in contrast to the majority of case reports sign or the patient’s motor function was not being moni-
where pain was present (Table 2). Table 3 details the simi- tored during the epidural infusion. Local anaesthetics and
larities and differences between the features of compart- opioids are considered to have similar pharmacological
ment syndrome and epidural analgesia. activities by some authors. For example, a 16-yr-old male
complained of discomfort and numbness in the leg after
an osteotomy of the distal femur and proximal tibia which
the author attributes to the pharmacological effects of an
Discussion epidural fentanyl infusion.49 Epidural opiates do not lead
The importance of pain in the diagnosis of compartment to numbness, paraesthesia, or motor block.41 The symp-
syndrome is controversial. Virtually, all analgesic modal- toms may well have been the clinical features of compart-
ities have been linked to a delayed diagnosis of compart- ment syndrome.
ment syndrome; however, only Level 3 evidence is Dense local anaesthetic blocks can influence the assess-
available. Reports commonly misattribute analgesia as the ment of pain and movement making the diagnosis of com-
cause rather than an association with a delayed diagnosis. partment syndrome difficult without invasive pressure
In addition, reports consistently reveal opportunities for monitoring. Dilute concentrations of local anaesthetics
improved clinical care including improvements in docu- avoid motor and dense sensory blocks. For example, the
mentation and postoperative monitoring for compartment optimal concentration of ropivacaine for epidural analgesia

6
 Table 2 Summary of reports relating epidural analgesia to delayed diagnosis of compartment syndrome. NS, not specified; Epi, epidural; GA, general anaesthesia; CSE, combined spinal and epidural; B0625,
bupivacaine 0.0625%; B1, bupivacaine 0.1%; B125, bupivacaine 0.125%; B2, bupivacaine 0.2%; B25, bupivacaine 0.25%; B5, bupivacaine 0.5%; L2, lidocaine 2%; M2, mepivacaine 2%; PCEA, patient-controlled
epidural analgesia; TKJR, total knee joint replacement; THJR, total hip joint replacement; CS, compartment syndrome; Postop analgesia, indicates analgesic type and duration of use (where specified). *Time to
fasciotomy from surgery or development of symptoms are estimated from case report details where possible

Report Patient Surgery Anaesthetic Postop analgesia Drug Significant other Signs/symptoms Classic CS Time to fasciotomy (h)* Pressure Outcome
age/gender issues symptoms monitoring
despite Epi From From utilized
initial symptoms
surgery of CS

Hailer and 43F TKJR Epi Epi till fasciotomy Ropivacaine and Paraesthesia, Yes 48 27 No Sensory, motor
colleagues18 sufentanil (no dose swelling, pain, deficit
details) increased analgesic
requirements

Acute compartment syndrome and the effect of postoperative analgesia

Kumar and 46F TKJR Epi Epi 20 h NS Obese (BMI 38) Tenseness, Yes 48 48 No No disability
colleagues29 swelling, pain once
Epi removed
71M THJR Epi Epi 28 h NS BMI 28 Pain 16 h after Epi Yes 44 34 No No disability
removed. Tense,
firm, tender,
swollen buttock
55M Hip resurfacing Epi Epi 19 h NS BMI 30 Pain 4 h after Epi Yes 28 23 No No disability
arthroplasty removed
72M TKJR Epi Epi 43 h NS Ankle paralysis not Foot drop, Yes 47 47 No Limp, weak
noticed till Epi paralysis, buttock abduction
ceased swelling
Benevides and 42M Duodenal switch Epi/GA NSAIDs/tramadol NS BMI 43, Pain, paraesthesia, Yes No fascitomy No fasciotomy No No disability
7

Nochi Junior3 procedure single-shot tenseness,

epidural injection swelling. Pain on
movement
Haggis and 69F TKJR revision Epi Epi till fasciotomy NS Intraop vascular No pain. Tight, Yes 14 NS No Foot drop, equinus
colleagues17 injury swollen calf
53M TKJR Epi Epi till fasciotomy NS Vascular Pain, cold, Yes 38 NS No Foot drop, equinus
compromise, pulselessness,
osteomyelitis swelling
48F TJKR Epi Epi 48 h NS Vascular Swelling, foot drop Yes 192 NS No Foot drop,
compromise numbness
49F Bilateral TKJR Epi Epi 32 h NS Pain, foot drop Yes 51 NS Yes Foot drop
61M TKJR Epi Epi 72 h NS Preop dalteparin Pain, paralysis, Yes 38 NS No Below knee
paraesthesia, tight amputation
swollen calf
Heyn and 52M Radical Epi/GA Epi till fasciotomy NS 7 h lithotomy Pain postop, pain Yes No delay No delay Yes No disability
colleagues22 prostatectomy passive stretch,
swelling
Bezwada and 60M Bilateral TKJR CSE Epi 1 day Bupivacaine and Diabetes, coronary Weakness, Yes 3 days 2 days No Reduced strength
colleagues4 fentanyl (no dose artery disease paralysis, swelling,
details) numbness
Somayaji and 39M THJR Epi/GA Epi 36 h B125 and fentanyl Dense block at 6 Pain after Epi No 24 No delay No Reduced abduction
colleagues57 and 24 h stopped, paralysis, and external
paraesthesia rotation
Stotts and 15F Spinal GA Epi till fasciotomy Hydromorphone Cramping in Yes 24 24 Yes No disability
colleagues58 instrumentation and PCA PCEA and PCA recovery. Pain,
and fusion morphine tenderness,
swelling

Continued

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 Table 2 Continued

Report Patient Surgery Anaesthetic Postop analgesia Drug Significant other Signs/symptoms Classic CS Time to fasciotomy (h)* Pressure Outcome
age/gender issues symptoms monitoring
despite Epi From From utilized
initial symptoms
surgery of CS

Pacheco and 47M TKJR Epi Epi 22 h NS Obesity (BMI 42), Back pain once No 44 15 Yes Gluteal pain
colleagues48 dense motor block Epi ceased, then
buttock pain
71M TKJR Epi Epi 43 h NS Dense motor block Foot drop, Yes 47.5 No delay No Lower leg motor
paraesthesia once and sensory
Epi ceased disability
Tang and Chiu60 62F TKJR Epi Epi till fasciotomy B125 Posterior Decreased Yes 2 days No delay Yes Numbness,
dislocation noted capillary return impaired walking
postop, dense (day 2), no pain,
block calf swelling
Dunwoody and 14M Hip osteotomy Epi/GA Epi 30 h B1 and fentanyl Developmental hip Pain, worse pain Yes 46 16 h Yes Paraesthesia,
colleagues10 dysplasia on movement weakness
7M Ilazarov frame/ Epi/GA Epi 1.5 days B25 and fentanyl Congenital short Decrease pulse, Yes 2 days 1 day Yes Decreased motion,
corticotomy femur calf spasm, normal sensation
reluctant to move
foot
Kontrbarsky and 69M Percutaneous Epi/GA Epi 18 h B125 and fentanyl Obesity, dense Buttock pain when No 18 No delay No NS
Love26 nephrolithotomy motor block Epi ceased
70M Ankle fusion CSE Epi 48 h B125 Obesity, sleep Buttock pain Yes No fasciotomy No fasciotomy No No disability

Mar et al.
apnoea, dense
8

motor block
Goldsmith and 48M Total colectomy Epi/GA Epi removed B5 Ulcerative colitis, Pain, tenseness, Yes 14 NS No Bilateral foot drop
McCallum15 postop 7 h lithotomy swelling,
tenderness
40M Laparotomy— Epi/GA Epi till fasciotomy B5 loading dose Ulcerative colitis, Pain, erythema, Yes No delay No delay No No disability
rectal excision then B125 and obese, 4 h tenderness
fentanyl infusion lithotomy (immediately
postop)
Nicholl and 65M THJR revision Epi/GA Epi 2 days Morphine Preop enoxaparin, Pain, pain with Yes 3 days 1 day Yes Decreased
colleagues43 electrical calf passive stretch, movement
stimulators swelling,
tenderness
Price and 16M Knee osteotomy GA Epi till fasciotomy Fentanyl Rickets ‘Uncomfortable’, Yes 18 NS Yes No disability
colleagues49 tenseness,
numbness
Seybold and 18M Scapular Epi/GA Epi till fasciotomy NS Obesity. 12 h Swelling, rigid Yes 14 2 Yes No disability
Busconi54 fasciocutaneous- procedure in lateral compartment. Pain
free flap grafting decubitus position. once Epi ceased
Total 4 h 48 min
tourniquet time
Tuckey65 28M Major laparotomy Epi/GA Epi 4 days B5 and fentanyl Ulcerative colitis Bilateral leg pain, Yes 15 No delay No Bilateral foot drop
intraop, B125 and tenseness,
fentanyl postop swelling,
tenderness
Slater and 40M Major laparotomy Epi/GA NS NS Ulcerative colitis, Pain, weakness Yes 2 days 1 day Yes Weakness
colleagues56 11 h lithotomy
Morrow and 18M Bilateral femoral GA Epi B2 and fentanyl Motor bike Unilateral paresis Yes 13 No delay Yes NS
colleagues39 IM nailing accident and anaesthesia,
‘turgid’ calf

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 Acute compartment syndrome and the effect of postoperative analgesia

Table 3 Signs attributable to compartment syndrome vs epidural infusions41

Not clear due to

Sensory, motor

other injuries
Analgesia Paraesthesia Anaesthesia Paralaysis Swelling

Slight limp

Slight limp
No injury

deficit
Compartment þ/2 þ þ þ þ
syndrome
Epidural
Low-dose þ þ/2 2 2 2
local anaesthetic
Higher dose þ þ þ þ 2
Yes

Yes

Yes

Yes

No
local anaesthetic
Opioids þ 2 2 2 2
No delay

4 days
23

16 and avoidance of motor block is 0.2%.52 This is often

6

combined with an opioid such as fentanyl 4 mg ml21 to

improve analgesia.53 The pathological pain of compart-
8 days ment syndrome is unlikely to be masked by analgesia pro-
18.5
1.5

23

16

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duced by dilute concentrations of local anaesthetic. One
example is the report where compartment syndrome was
promptly diagnosed and treated in the presence of an epi-
Yes

Yes

Yes

Yes

Yes

dural infusion with bupivacaine 0.125% and fentanyl.2 In

tightness, swelling

contrast, the hazards of dense epidural block are high-

paralysis in ankle

once Epi ceased

Pain, tenseness,

Pain, tenseness,

pain on passive
Numbness and

swelling, pain,
muscle spasm,

Swelling, pain

lighted in three reports of compartment syndrome in

pulselessness

and great toe

paraesthesia,

Numbness,

which patients had dense bilateral motor blocks.26 57 60

swelling,

swelling,

stretch

Epidural analgesia provides effective pain relief after

lower limb surgery, but should be supervised by an acute
pain or anaesthetic service in order to derive the greatest
10.5 h lithotomy

11.5 h lithotomy
7.5 h lithotomy

11 h lithotomy

benefit and avoid potential complications.61 An alternative

non-union
Infected

to epidural analgesia is continuous PNB (CPNB) and prob-

tibia

ably represents the gold standard for postoperative analge-

sia after major unilateral surgery. CPNB is associated with
intraop, B125 and
B5 and fentanyl

a reduced incidence of side-effects when compared with

fentanyl postop

fentanyl postop
B0625 intraop,
L2 intraop and
morphine after

morphine and

epidural analgesia.12 The use of CPNB is increasing as the

lidocaine in
M2 intraop,

recovery

evidence for their efficacy increases. In a meta-analysis,

B125

perineural analgesia provided postoperative analgesia that

was superior to opioids for all time periods and all catheter
Epi till fasciotomy

Epi till fasciotomy

Epi till fasciotomy

locations.51 Ultrasound imaging aids precise perineural

Epi 4 days

injection and may also facilitate the use of dilute concen-

trations of local anaesthetics for both the primary block
Epi

and the subsequent infusion through the catheter in

patients at risk of compartment syndrome. Local anaes-
thetics used with CPNB have included ropivacaine 0.2%
or bupivacaine 0.25%8 and in a comparative study ropiva-
Epi/GA

Epi/GA

Epi/GA

Epi/GA

caine 0.2% was as effective as ropivacaine 0.3%.6

Epi

A limitation of this review was that the data available

were mainly from case reports and therefore statistical
Osteocutaneous-
reconstruction
genitourinary

analysis was not possible. There may also be significant

cystectomy

cystectomy

free fibular
Urological

underreporting of complications like compartment syn-

Radical

Radical

transfer
Repair

fistula

drome, especially where medico-legal proceedings may be

involved.
45M
76F

15F

52F

17F

Conclusion
Beerle and Rose2

Montgomery and

Compartment syndrome is challenging to diagnose and

Strecker and
Iwasaka and
colleagues24

colleagues59

requires urgent treatment in order to avoid disastrous com-

Ready38

plications. This systematic review does not provide con-

vincing evidence that PCA opioids or regional analgesia

9
 Mar et al.

delay the diagnosis of compartment syndrome. Whatever 15 Goldsmith AL, McCallum MI. Compartment syndrome as a com-
the mode of analgesia used, a high index of clinical suspi- plication of the prolonged use of the Lloyd– Davies position.
cion, ongoing assessment of patients, and compartment Anaesthesia 1996; 51: 1048 –52
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