Compartment syndrome of extremities

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute with occlusive dressing

1st line – dressing release

Back

1st line –

dressing release

Casts or occlusive dressings should be split completely. Padding or circumferential dressings should be released immediately.[20]

Plus – supportive therapies

Back

Plus –

supportive therapies

Treatment recommended for ALL patients in selected patient group

Nonsteroidal anti-inflammatory drugs, such as ibuprofen, 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.

Primary options

ibuprofen: children ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required, or 10-30 mg orally (immediate-release) every 4 hours when required, titrate dose according to response

2nd line – fasciotomy

Back

2nd line –

fasciotomy

When the clinical diagnosis is clear, fasciotomy is indicated. 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 Orthopaedic Surgeons advise 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. They decrease the risk of excess skin acting as a compartment envelope. Necrotic muscle should be excised.[20]

Muscle viability can also be checked intraoperatively.

Postfasciotomy: wound care is 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] 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]

Physical and occupational therapies (with range of motion exercises) are important components of the postoperative treatment.

Plus – supportive therapies

Back

Plus –

supportive therapies

Treatment recommended for ALL patients in selected patient group

Nonsteroidal anti-inflammatory drugs, such as ibuprofen, 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.

Primary options

Secondary options

3rd line – amputation

Back

3rd line –

amputation

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.

with rhabdomyolysis

Plus – continued hydration therapy +/- urinary alkalinization +/- hemodialysis

Back

Plus –

continued hydration therapy +/- urinary alkalinization +/- hemodialysis

Treatment recommended for ALL patients in selected patient group

Patients should continue to receive adequate amounts of fluids. In cases of rhabdomyolysis, sodium bicarbonate for urinary alkalinization may be indicated. Myoglobin is toxic to renal tubules in acidic urine, and some specialists recommend concurrent use of intravenous sodium bicarbonate to alkalinize the urine and prevent crystallization 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 specialists may recommend urine alkalinization, 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 alkalinization, pharmacy consultation should be considered to determine appropriate continuous intravenous therapy mixtures. Patients with anuria unresponsive to hydration may require hemodialysis.[36] Hemodialysis corrects metabolic acidosis and electrolyte abnormalities, and removes plasma myonecrotic toxins. See Rhabdomyolysis.

acute without occlusive dressing

1st line – fasciotomy

Back

1st line –

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 Orthopaedic Surgeons advise 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.

Physical and occupational therapies (with range of motion exercises) are important components of the postoperative treatment.

Plus – supportive therapies

Back

Plus –

supportive therapies

Treatment recommended for ALL patients in selected patient group

Nonsteroidal anti-inflammatory drugs, such as ibuprofen, 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.

Primary options

Secondary options

2nd line – amputation

Back

2nd line –

amputation

with rhabdomyolysis

Plus – continued hydration therapy +/- urinary alkalinization +/- hemodialysis

Back

Plus –

continued hydration therapy +/- urinary alkalinization +/- hemodialysis

Treatment recommended for ALL patients in selected patient group

Patients should continue to receive adequate amounts of fluids. In cases of rhabdomyolysis, patients should also receive sodium bicarbonate for urinary alkalinization may be indicated. Myoglobin is toxic to renal tubules in acidic urine, and some specialists recommend concurrent use of intravenous sodium bicarbonate to alkalinize the urine and prevent crystallization 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 specialists may recommend urine alkalinization, 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 alkalinization, pharmacy consult should be considered to determine appropriate continuous intravenous therapy mixtures. Patients with anuria unresponsive to hydration may require hemodialysis.[36] Hemodialysis corrects metabolic acidosis and electrolyte abnormalities, and removes plasma myonecrotic toxins. See Rhabdomyolysis.

ONGOING

chronic

1st line – exercise limitation and nonsteroidal anti-inflammatory drug (NSAID)

Back

1st line –

exercise limitation and nonsteroidal anti-inflammatory drug (NSAID)

Conservative treatment may involve prolonged rest and modifying offending activities. NSAIDs can be successful if patients are willing to significantly limit their athletic activities.

Treatment course limited to 7-14 days.

Primary options

2nd line – fasciotomy

Back

2nd line –

fasciotomy

Most patients continue their activities and eventually require fasciotomy of the involved compartment.[38]

Physical and occupational therapies (with range of motion exercises) are important components of the postoperative treatment.

Use of this content is subject to our disclaimer

Compartment syndrome of extremities

Treatment algorithm

acute with occlusive dressing

dressing release

supportive therapies

Primary options

Secondary options

fasciotomy

supportive therapies

Primary options

Secondary options

amputation

continued hydration therapy +/- urinary alkalinization +/- hemodialysis

acute without occlusive dressing

fasciotomy

supportive therapies

Primary options

Secondary options

amputation

continued hydration therapy +/- urinary alkalinization +/- hemodialysis

chronic

exercise limitation and nonsteroidal anti-inflammatory drug (NSAID)

Primary options

fasciotomy