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 |Favorite Table|Download (.pdf) TABLE 93-1 Etiologies of a Compartment Syndrome
Anticoagulation therapy or coagulopathy
Bleeding into compartment
Burns involving muscle (i.e., electrical or thermal)
Chronic exertional compartment syndrome
Iatrogenic closure of fascial injuries
Improper casting or tight dressings
Infiltration of infusion fluids into muscle compartment
Intraosseous infusion leak
Nephrotic syndrome (e.g., lower extremity swelling)
Reperfusion after ischemia
Reperfusion injury after prolonged positioning or tourniquet use
Seizures causing increased capillary permeability
Long bone fractures
Blunt trauma (i.e., crush injury)
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 ...