Compartment Syndrome
Musculoskeletal compartment syndrome is a limb threatening condition resulting
from increased pressure within a muscular compartment, which causes compression
of the nerves, muscles and vessels within the compartment.
Causes
Compartment syndrome is usually caused by fractures, especially tibia, humeral
shaft, combined radius and ulna fractures, and supracondylar fractures in children
• may be open or closed
Compartment syndrome can also occur after a soft tissue injuries due to:
• crush injury
• snake bite
• excessive exertion
• prolonged immobilisation
• constrictive dressings and plaster casts
• soft tissue infection
• seizures
• extravasation of intravenous fluids and medications
• burns
• tourniquets
Patients with a coagulopathy are at particular risk of compartment syndrome.
Compartment syndrome affect many regions of the body:
• the forearm (volar compartment) and leg (the anterior compartment — the
anatomical leg being the bit below the knee…) are most commonly affected.
Complications include:
• gangrene or loss of limb viability requiring amputation
• ischemic contracture and loss of function
• rhabdomyolysis and renal failure
Assessment
History
• suspect if:
• one of the fractures listed above is present
• one of the soft tissue injuries listed above is present (e.g. crush injury)
• patient has a coexistent bleeding dosorder or coagulopathy
• Remember the 6Ps
1. pain (especially on passive stretching)
2. pallor
3. perishingly cold
4. pulselessness
5. paralysis
6. paraesthesiae
• Pain is the key symptom. It occurs early, is persistent, tends to be
disproportionate compared with the original injury and is not relieved by
immobilisation.
Examination
• Pain is exacerbated by passive stretching, which is the most sensitive sign.
• The extremity may be swollen and affected compartments may feel tense and
tender on palpation.
• Assess loss of sensation by light touch and two-point discrimination, rather
than just pinprick, which is less sensitive.
Compartment pressure measurement
• Measurement of elevated compartment pressures are not essential for the
diagnosis if the clinical picture is compelling.
• This measurement should be used to determine the need for fasciotomy.
• A commercial device like the Stryker STIC Device is probably the easiest and
most accurate means of measuring compartment pressures.
• Compartment pressures may also be obtained using an angiocath connected
to a blood pressure transducer (e.g. arterial line set up).
• Other options for measuring compartment pressures include the needle
technique, the wick catheter, and the slit catheter.
Imaging
Imaging has no role in the diagnosis of compartment syndrome, but may show the
presence of fractures and soft tissue injuries that are associated with the condition.
Management
Resuscitation
• attend to any coexistent life threats
• ensure adequate oxygenation and systemic circulation if compartment
syndrome is potentially present
Specific treatment
• arrange immediate fasciotomy
• remove all constrictive dressings
• elevate the limb to the level of the heart
• consider injury specific measures:
• relieve flexion of the elbow if the forearm is involved
• apply traction for a partially reduced supracondylar fracture
• if there is no relief within 30 minutes, go straight to the operating theatre
Indications for fasciotomy
• A delta pressure <20 mmHg is a definite indication for fasciotomy, <30 mmHg
may be a relative indication
• clinical signs of acute compartment syndrome
• absolute pressure is >30 mmHg and the clinical picture is consistent with
compartment syndrome
• arterial perfusion has been interrupted for 4 or more hours
Supportive care and monitoring
• provide adequate analgesia
• provide IV hydration to maintain an adequate urine output in case of
rhabdomyolysis
• frequent monitoring of compartments and neurovascular status of the affected
limb
Disposition
• urgent surgical referral (usually an orthopedic surgeon) and transfer to the
operating theatre
• patients require admission for ongoing monitoring
Anterior leg compartment fasciotomy
