Compartment Syndrome: Emergency Management, and Surgical Treatment

Understanding Compartment Syndrome: A Surgical Emergency

Compartment syndrome is a potentially limb-threatening condition that occurs when pressure builds up within a muscle compartment enclosed by fascia. This increased pressure compromises blood flow, leading to tissue ischemia and, if untreated, muscle and nerve necrosis. Recognizing and treating compartment syndrome promptly is crucial to prevent permanent disability.

Other Ortho Topics: Orthopedics Surgery

Key Features of Compartment Syndrome

• Pain out of proportion to the injury
• Pain on passive stretching of affected muscles
• Paresthesia (tingling/numbness) in the nerve distribution
• Tense, swollen compartment
• Weakness in involved muscles

⚠️ Critical Note:

• Pulses may remain normal—their absence suggests late-stage damage.
• Not the same as the “6 Ps” of ischemia (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia).

Causes of Compartment Syndrome

Several mechanisms can lead to increased intracompartmental pressure:

1. Fractures (Most Common Cause)

• Tibial fractures are high-risk, but forearm fractures can also cause it.
• Open fractures do not prevent compartment syndrome—fascial disruption is rarely enough to decompress the compartment.

2. Blunt Trauma

• Direct muscle contusions (e.g., thigh crush injury).

3. Hemorrhage

• Anticoagulant use increases bleeding risk.

4. Extravasation Injury

• IV fluid infiltration or irritant injections into muscle.

5. Reperfusion Injury

• After revascularization of an ischemic limb.
• Following prolonged limb compression (e.g., unconscious patient lying in one position).

Emergency Department Management

Immediate Actions

1. Remove Constrictive Dressings – Split casts/bandages fully.
2. Position Limb at Heart Level – Avoid excessive elevation.
3. Realign Fractures – Reduce displaced bones to relieve pressure.
4. Urgent Surgical Consultation – Fasciotomy may be required immediately.

Diagnosis: Clinical vs. Pressure Monitoring

• Clinical Diagnosis = Surgery without delay.
• Uncertain Cases → Admit for serial exams and compartment pressure monitoring.

Compartment Pressure Monitoring Technique

Equipment Needed

• 14G spinal cannula (or large IV cannula)
• No. 11 blade scalpel
• Sterile saline, syringe, pressure transducer

Step-by-Step Procedure

1. Entry Point Selection
   • Anterior leg compartment (2 cm lateral to tibia, 10 cm from fracture).
2. Skin Prep & Local Anesthetic
   • Small stab incision (5 mm).
3. Cannula Insertion
   • 45° angle through fascia → 20° advancement parallel to bone.
4. Pressure Measurement
   • ∆P = Diastolic BP – Compartment Pressure
   • ∆P < 30 mmHg = Compartment syndrome

Surgical Treatment: Fasciotomy

Leg Fasciotomy (4 Compartments)

1. Medial Incision
   • Posterior & deep compartments released.
   • Protect saphenous vein & nerve.
2. Lateral Incision
   • Anterior & lateral compartments released.
   • Avoid superficial peroneal nerve.

Muscle Viability Check (“4 Cs”)

• Color (pink = viable)
• Contractility (responds to stimulation)
• Consistency (firm vs. mushy)
• Capacity to Bleed

Post-Fasciotomy Care

• Leave wounds open (vacuum dressing).
• 48-hour re-exploration for debridement.
• Delayed closure/skin grafting later.

Neglected Compartment Syndrome

If diagnosis is delayed (>24-48 hrs):

• Muscle necrosis is likely irreversible.
• High infection risk with late fasciotomy.
• Amputation or joint fusion may be needed**.

Key Takeaways

✅ Early diagnosis prevents permanent damage.
✅ Pain + tense compartment = Fasciotomy NOW.
✅ Pressure monitoring aids uncertain cases.
✅ Never ignore just because pulses are present.

Also read: Abdominal Compartment syndrome

For Further Reading:

• AAOS Guidelines
• Wikipedia: Compartment Syndrome