Compartment syndrome
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Compartment Syndrome
Compartment syndrome is a condition where pressure within a closed fascial compartment rises to a level that compromises tissue perfusion, leading to progressive ischemia and potentially irreversible muscle and nerve damage. It is a surgical emergency.
Anatomy
Muscles are enclosed within fascial compartments. The leg has four compartments (anterior, lateral, superficial posterior, and deep posterior); the forearm has three (superficial volar, deep volar, and dorsal). Because fascia is inelastic, any increase in compartment volume or decrease in compartment size raises pressure rapidly.
Types
| Type | Description |
|---|---|
| Acute | Surgical emergency; most common after fracture or crush injury |
| Chronic (exertional) | Seen in athletes; exercise-induced pain that resolves with rest; no emergency |
| Abdominal | Elevated intra-abdominal pressure >20 mmHg with new organ dysfunction |
Causes of Acute Compartment Syndrome
Most common: Fractures (70%), especially proximal/midshaft tibial fractures (~36% of lower leg cases).
Other causes include:
- Soft tissue contusions (23%)
- Crush injuries, gunshot wounds
- Vascular injury / reperfusion after ischemia (reperfusion injury releases oxygen free radicals, triggers lipid peroxidation and calcium influx, driving progressive edema)
- Circumferential third-degree burns
- Tight casts or dressings
- Extravasation of IV infusions
- Bleeding disorders / anticoagulation
- Prolonged exertion (rare)
High-risk demographics: Males under 55 years; patients on anticoagulation.
Bailey and Love's Short Practice of Surgery 28th Ed, p. 466; Campbell's Operative Orthopaedics 15th Ed, Box 53.2
Pathophysiology
- Tissue volume increases (hemorrhage, edema) or container shrinks (tight cast)
- Pressure in the closed compartment rises
- Venous outflow is impaired first, creating a positive-feedback loop of increasing edema
- Capillary perfusion pressure is exceeded - tissue ischemia begins
- Irreversible muscle necrosis occurs from cellular anoxia
- Nerve damage follows (non-myelinated type C sensory fibers are most sensitive to hypoxia)
- Systemically: rhabdomyolysis, myoglobinuria, acute tubular necrosis, renal failure
Rosen's Emergency Medicine 9e, Chapter 40
Clinical Features
Compartment syndrome is a clinical diagnosis.
The "6 Ps" (in order of appearance)
| Sign | Timing | Notes |
|---|---|---|
| Pain out of proportion | Early | Most sensitive sign |
| Pain on passive stretch | Early | Most important clinical sign |
| Pressure (tense compartment) | Early | Firm, woody feel on palpation |
| Paraesthesia / Paresthesia | Intermediate | Nerve ischemia |
| Paralysis | Late | Muscle ischemia advanced |
| Pallor + Pulselessness | Very late | Near-terminal finding; does NOT rule out CS if absent |
Critical point: Pulselessness is an extremely late sign. The presence of palpable pulses does NOT rule out compartment syndrome. Do not wait for it. - Bailey and Love, p. 466
Key warning: Do not dismiss escalating analgesic requirements as drug-seeking behavior - this should prompt urgent evaluation for compartment syndrome.
Rockwood and Green's Fractures in Adults 10th Ed 2025, Chapter 63; Bailey and Love, p. 466
Compartment Pressure Measurement
Used when clinical diagnosis is uncertain (e.g., sedated patient, altered consciousness, head injury).
Techniques: Slit catheter, wick catheter, handheld Stryker device
Thresholds for fasciotomy:
- Absolute pressure ≥ 30 mmHg (Mubarak/Hargens criterion)
- Delta pressure (ΔP) = Diastolic BP - Compartment pressure ≤ 30 mmHg (Bailey & Love)
- Some sources use ΔP < 10-20 mmHg as a more aggressive threshold
- High clinical suspicion warrants fasciotomy even with normal pressures
Important: Measure multiple sites and all compartments in the affected limb. Elevated CPK and myoglobinuria are late markers of tissue destruction - do not use them to establish or exclude the diagnosis.
Roberts and Hedges' Clinical Procedures in Emergency Medicine; Current Surgical Therapy 14e, p. 1155
Management
Immediate (Emergency)
- Remove or split all circumferential casts, dressings, and bandages down to skin
- Elevate the limb
- Seek senior/surgical input immediately
- Do NOT delay for imaging if clinical diagnosis is clear
Definitive: Fasciotomy
Fasciotomy should be performed without delay once diagnosis is made. There are no contraindications - though correction of coagulopathy is preferred when time allows. - Fischer's Mastery of Surgery 8e
Indications for fasciotomy:
- Compartment pressure ≥ 30 mmHg
- ΔP ≤ 30 mmHg (diastolic - compartment pressure)
- High clinical suspicion regardless of pressure
Lower leg: Four-compartment fasciotomy via double-incision technique (lateral and medial incisions). A single perifibular incision may be used if soft tissue is not extensively distorted, but double-incision is generally safer.
Forearm: Volar (superficial + deep) and dorsal compartment releases. If swelling extends to the hand, carpal tunnel release and hand fasciotomies may also be required.
Post-fasciotomy: Wounds are left open. Vacuum-assisted closure (VAC) is applied. Return to OR at 48-72 hours for debridement. Delayed primary closure or skin grafting once swelling resolves.
Campbell's Operative Orthopaedics 15th Ed 2026; Current Surgical Therapy 14e, p. 1155
Timing matters critically:
- Fasciotomy < 12 hours from onset: ~68% good results
- Fasciotomy > 12 hours from onset: ~8% good results
Campbell's Operative Orthopaedics 15th Ed 2026
Prophylactic Fasciotomy
Indicated when prolonged ischemia (>6 hours) preceded revascularization or when limb edema is observed after arterial repair. The more severe the prior ischemia, the more likely reperfusion compartment syndrome will develop. Liberal use of four-compartment calf (with or without thigh) fasciotomies following revascularization of a prolonged ischemic limb is advisable.
Current Surgical Therapy 14e, p. 1155; Bailey and Love, p. 461
Chronic Exertional Compartment Syndrome
- Typical in athletes; most common in the anterolateral leg compartment
- Aching/cramping starting within 10-30 min of exercise, resolving with rest
- No signs at rest - diagnosis requires history + intracompartmental pressure measurement before and after exercise in a specialized center
- Fascial defects may be found on MRI in up to 40% of patients
- Treatment: activity modification, or elective fasciotomy in refractory cases
Rheumatology 2-Volume Set (2022, Elsevier)
Complications of Untreated Compartment Syndrome
- Volkmann's ischemic contracture (forearm)
- Rhabdomyolysis - acute kidney injury / ATN
- Permanent sensorimotor deficits
- Limb loss / amputation
- Death (in severe cases with systemic involvement)
Key Pitfalls
- Compartment syndrome can occur in open fractures - do not assume an open wound decompresses all compartments
- High-energy and low-energy injuries have nearly equal incidence of compartment syndrome
- Pulselessness is not required for diagnosis - it is a very late sign
- Sedated or obtunded patients cannot report pain - maintain high suspicion and use pressure monitoring
- Elevated CPK/myoglobinuria confirm damage but are not diagnostic tools
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