Approach

In cases of acute extremity compartment syndrome, fasciotomy is required in an emergent fashion.[25] If delayed diagnosis leads to significant muscle necrosis, amputation may need to be considered. This is best done in a staged procedure after multidisciplinary consensus and discussion with the patient.

Acute compartment syndrome

In cases of high index of suspicion, immediate measures are necessary to make an accurate and timely diagnosis and to prevent complications. Casts or occlusive dressings should be split completely, and padding or circumferential dressings should be released.[20]​ If symptoms are not relieved with removal, fasciotomy is indicated.[20]

Supportive measures include analgesia and fluids. Non-steroidal anti-inflammatory drugs (NSAIDs) may be effective. Patient-controlled analgesia, with either morphine or another opioid analgesic medication, is usually effective. Patients should also receive adequate amounts of fluids. In cases of rhabdomyolysis, sodium bicarbonate for urinary alkalinisation may be indicated. Myoglobin is toxic to renal tubules in acidic urine, and some consultants recommend concurrent use of intravenous sodium bicarbonate to alkalinise the urine and prevent crystallisation of uric acid. Some evidence suggests that a urine pH >6.0 is protective.[30][31]​​​​​​ This is difficult to achieve without the use of large amounts of bicarbonate and, although some consultants may recommend urine alkalinisation, benefits of its use lack robust evidence-based support.[31][32][33]​​​​​​[34]​​ European protocols report limited clinical evidence to support bicarbonate therapy.[35]​ Should the clinical decision be made to attempt urine alkalinisation, pharmacy consultation should be considered to determine appropriate continuous intravenous therapy mixtures. Patients with anuria unresponsive to hydration may require haemodialysis.[36] See Rhabdomyolysis.​

Fasciotomy

When the clinical diagnosis is clear, complete fasciotomy of all compartments with elevated pressures is necessary.​[7][20][25]​​​ Fasciotomy performed within a 6-hour window from the initiation of compartment syndrome leads to lower compartment syndrome-related amputation and death rates, compared with delays >6 hours.[25][37]​​ For lower leg fasciotomies, it is generally recommended to perform a two-incision four-compartment decompression.[17][20]​​​​ However, the American Academy of Orthopedic Surgeons advises that fasciotomy technique (e.g., one vs. two incision, placement of incisions) is less important than achieving complete decompression of the compartments of the affected extremity.[6]​ If a two-incision approach is chosen for lower-extremity compartment syndrome, the lateral incision decompresses the anterior and lateral compartments, whereas the medial incision decompresses the superficial and deep posterior compartments.

The length of skin incision affects fascial decompression in the extremity with an acute compartment syndrome. Long incisions do not cause significant additional morbidity and do not further influence the complication rate or the functional result. Moreover, they decrease the risk of excess skin acting as a compartment envelope. Necrotic muscle should be excised.[20]

Limited evidence suggests that performing fasciotomy is unlikely to be useful in patients with evidence of irreversible intracompartmental (neuromuscular/vascular) damage.[6]​ Fracture stabilisation, if warranted in these patients, should use a technique (external fixation/casting) that does not violate the compartment.[6]

Post-fasciotomy, the following measures should be considered:[25]

  • Wound care, important due to the secondary risk of infection and to identify in a timely fashion the presence of necrotic tissue that needs to be debrided.

  • The wounds should be left open and dressed sterilely.[17]​ Early closure of fasciotomy wounds has been associated with recurrence of acute extremity compartment syndrome.[17][18]​​

  • Early involvement by a plastic surgeon may be required to achieve appropriate soft tissue coverage.[20]

  • Rest, analgesia, and physical and occupational therapy (with range of motion exercises).

  • Limited evidence supports the use of negative pressure wound therapy for management of fasciotomy wounds to reduce the time to wound closure and need for skin grafting.[6]

If delayed diagnosis leads to significant muscle necrosis, amputation may need to be considered. This is best done in a staged procedure after multidisciplinary consensus and discussion with the patient.

Chronic exertional compartment syndrome

Conservative treatment may involve prolonged rest and modifying offending activities. NSAIDs can be successful if patients are willing to significantly limit their athletic activities. Most patients, however, continue their activities and eventually require fasciotomy of the involved compartment.[38]

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