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  Compartment syndrome occurs when tissue pressure in a closed space rises, compromising perfusion to nerves and muscles.

  
  
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  The leg and forearm compartments are most commonly involved, but compartment syndrome can also occur in the upper arm, thigh, hand, foot, gluteal region, or abdomen.

  
  
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  Compartment syndrome is usually associated with long bone fracture, crush injuries, circumferential burn, or cast.

  
  
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  Acute compartment syndrome is a surgical emergency, treated by fasciotomy to relieve pressure and restore circulation.

Acute compartment syndrome is a surgical emergency. If unrecognized and untreated, it can lead to tissue ischemia, necrosis, and long-term functional impairment. Volkmann ischemic contracture is the end result of an ischemic injury to the muscles and nerves of a limb. Compartment syndrome is seen most commonly in the setting of trauma, including long bone fractures, crush injuries, and circumferential burns to the extremities. Males and young people are affected more commonly than females and elderly.

The pathophysiology of compartment syndrome involves increased pressure in a muscle compartment that is enclosed by a fascial structure with limited ability to expand. This increased pressure is caused by edema or bleeding, from compression of the compartment by a circumferential burn or a constricting cast, or a combination of both. Increased pressure leads to decreased venous outflow from the compartment, causing a decrease in the arteriovenous pressure gradient and ultimately cellular ischemia and tissue necrosis.

Cardinal signs and symptoms include severe pain over the involved area, pain with passive stretch of the muscles in the affected compartment, weakness, and paresthesias. Although commercially available devices can be used to measure compartment pressures, the diagnosis is often made on clinical grounds alone. Early recognition and orthopedic consultation are essential in preventing tissue necrosis and adverse outcome.

History

Acute compartment syndrome is seen most commonly in the setting of trauma or long bone fracture. Significant blunt trauma or crush injury can lead to compartment syndrome, even in the absence of fracture. Symptom onset is usually within hours of injury, but can present up to 48 hours after the traumatic event.

Historically, the symptoms of compartment syndrome have been described by the “the five Ps”: pain, pallor, paresthesias, pulselessness, and poikilothermia. However, all of these are not typically present, and many are late findings that signal irreversible injury. The primary complaint in the alert patient is usually of severe pain in the affected limb, often not controlled by opioid analgesics. The pain is often worsened by passive stretch of the muscles in the involved compartment. Nerve ischemia can lead to a burning sensation or dysesthesia.

Physical Examination

Detection of compartment syndrome requires a high clinical suspicion and an attentive exam. The involved compartment is swollen and tense. There is exquisite tenderness to palpation. Pain is intensified if the examiner passively stretches the muscles of the compartment. Sensory deficits may be present, but motor weakness is usually a later finding. Pulselessness is a rare and late finding, as the arterial pressure usually exceeds the tissue pressure. Thus, the limb often remains warm with normal color, pulses, and capillary refill. In the alert patient, the absence of pain, paresthesias, and pain with passive stretch excludes the diagnosis of compartment syndrome.