Acute Compartment Syndrome
Cardinal Presentations / Presenting Problems, Inflammatory, Orthopedic
- 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:
- 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
Criteria For Hospital Admission
- 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.
Criteria For Transfer To Another Facility
- Dependent on local guidelines.
Criteria For Close Observation And/or Consult
- Suspected or diagnosis of ACS warrants surgical consultation and close observation.
Criteria For Safe Discharge Home
- Dependent on surgical outcome and clinical presentation.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Intracompartmental pressure monitoring assists in diagnosing acute compartment syndrome.
Repeated/continuous intracompartmental pressure monitoring and a differential pressure threshold of > 30 mmHg assists in ruling out ACS.
Myoglobinuria and serum troponin level may assist in diagnosing acute compartment syndrome in patients with traumatic lower extremity injury.
Serial clinical exam findings may assist in ruling in ACS in the awake patient.
OTHER RELEVANT INFORMATION
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
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 28, 2020
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