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INTRODUCTION

The ability to diagnose a compartment syndrome is a critical skill for the Emergency Physician (EP). Early identification of a compartment syndrome can enable the appropriate treatment and may facilitate limb salvage. A compartment syndrome begins when pressure within a myofascial compartment increases to the point that it results in diminished blood flow.1,2 A compartment syndrome has been classically described in the early literature as a Volkmann ischemic contracture following vascular insufficiency in the forearm.3 A compartment syndrome is described as the 6 Ps (i.e., pain out of proportion, pallor, paralysis, paresthesias, pressure, and pulselessness).

A compartment syndrome can occur in almost any muscle group contained within a confined fascial space. Common locations include the leg, forearm, and gluteal area. There are many causes of a compartment syndrome. These include protracted muscle ischemia (e.g., necrosis from a contusion), swelling (e.g., fracture or volume overload), or a thrombus in a vessel that traverses the compartment. A compartment syndrome in the Emergency Department (ED) is most commonly associated with long bone fractures or blunt trauma.4 Most compartment syndromes are caused by trauma.2 Approximately 58% of cases are due to fractures of the tibia or forearm.5 Other etiologies for a compartment syndrome include complications from a coagulopathy, dialysis, surgery, or states of obtundation (Table 93-1).2,6-18

TABLE 93-1Etiologies of a Compartment Syndrome

Identifying a compartment syndrome in a timely fashion can be challenging. The sensitivity and specificity of manual palpation to identify a compartment syndrome are 24% and 55%, respectively.19 Manual palpation has a positive predictive value of 19% and a negative predictive value of 63%.19 Manual palpation cannot be used to rule-in or rule-out a compartment syndrome.

The hallmark symptom of a compartment syndrome is persistent and progressive pain disproportionate to the underlying cause. The pain typically increases with passive motion. A common and dangerous mistake is to attribute the etiology of the patient’s pain solely to the underlying problem (e.g., fracture or trauma).20,21 Other signs and symptoms associated with a compartment syndrome occur late in the disease course and include paresthesias of the involved nerve, paralysis of the involved muscle group, pallor of the skin, and ...

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