• Normal extremity tissue compartment pressure is usually 8 – 10 mmHg in adults and 10 – 15 mmHg in children.
• Acute compartment syndrome (ACS) is a rare surgical emergency caused by excessive pressure (> 20 – 30 mmHg) within a fascial compartment leading to reduced perfusion within this compartment.
• This can be caused by any condition that increases the volume inside a compartment (e.g. edema, hematoma) or decreases the compartment size (e.g. body positioning, tight casts/wound dressings).
• Prompt recognition and definitive treatment (i.e. fasciotomy/cast replacement) is necessary to reduce morbidity and long-term neurovascular deficits.
• ACS is most common among patients < 35 years old due to stronger fascial structures, increased muscle bulk, and increased likelihood of experiencing high-energy injuries. It is 10 times more common in males than females. 75% of ACS is caused by fractures, with the anterior tibia being the highest risk area.
• Increased pressure compromises microcirculation, lymphatic flow, capillary flow, venule flow, and finally arterial flow. If left untreated, fibrous tissues degeneration, inflammation, neurologic damage, necrosis, and contractures occur. Amputation may be necessary.
• Early ACS: Pathologic tissue pressure elevation present for < 4 hours
  • Good likelihood of reversing muscle injury with treatment
• Late ACS: Pathologic tissue pressure elevation present for > 4 hours
  • Muscle damage generally begins after 4 hours of muscle ischemia
  • Injury is usually irreversible after 12 hours of elevated pressures
• Clinical findings include pain out of proportion to presentation, paresthesias, firm/swollen limb, aching/burning sensation, pain on passive stretch of muscle in suspected compartment, paralysis, pulselessness, and pallor. However, these signs have poor sensitivity and early findings may be limited to pain or vague discomfort so intracompartment pressure measurement should be considered if ACS is suspected.
• ACS of an extremity is a clinical diagnosis based on the mechanism of injury and examination findings. Compartment pressures measurements are an important adjunct but not required. A differential pressure (diastolic blood pressure – intracompartmental pressure) < 30 mm Hg strongly suggests ACS.

• Immediate removal of external pressure on affected compartment (e.g. removing dressing, clothes, cast).
• Place the limb at the level of the heart to improve arterial inflow.
• Reduced any fractures if possible.
• Fluid resuscitation as needed.
• Administer analgesics as needed.
• Immediate surgical consultation for consideration of fasciotomy.
• Bedside fasciotomy (see video below) made be indicated depending on local guidelines.

The procedure may be carried out if:^[4]

• There are strong signs of compartment syndrome
• Pressures in the compartment are > 30 mmHg (> 20 mmHg if a persons blood pressure is low)
• There is no arterial blood flow to the area for > 4 hrs

• Patients with or suspected to have acute compartment syndrome are to be admitted.  However, orthopedics may discharge if they have assessed patient and diagnosis not clear.

• Dependent on local guidelines.

• Suspected or diagnosis of ACS warrants surgical consultation and close observation.

• Dependent on surgical outcome and clinical presentation.

1. Bedside Fasciotomy For Compartment Syndrome (Video)

   
   

2. Compartment Pressure Measurement (Video)

   
   

1. Graff, D. M., Brey, J., & Herr, S. (2016). Traumatic pediatric orthopedic emergencies: an approach to evaluation and management. Clinical Pediatric Emergency Medicine, 17(1), 3-12.

   
   

2. Long, B., Koyfman, A., & Gottlieb, M. (2019). Evaluation and Management of Acute Compartment Syndrome in the Emergency Department. The Journal of emergency medicine, 56(4), 386-397.

   
   

3. Osborn, C. M. & Schmidt, A. H. (2019). Management of Acute Compartment Syndrome. Journal of the American Academy of Orthopaedic Surgeons, Publish Ahead of Print,doi: 10.5435/JAAOS-D-19-00270.

   
   

4. Perron, A. D., Brady, W. J., & Keats, T. E. (2001). Orthopedic pitfalls in the ED: acute compartment syndrome. The American journal of emergency medicine, 19(5), 413-416.

   
   

5. Stracciolini, A., Hammerberg, E. M. (2019). Acute compartment syndrome of the extremities. In J. Grayzel (Ed.), UpToDate. Retrieved November 11, 2019, from https://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities