Compartment Syndrome: Pearls and Pitfalls

Author: Alex Koyfman, MD // Editor: Justin Bright, MD

Your next 3 patients…

#1) 23yo MMA fighter with low back pain

#2) 29yo M presents as pedestrian  versus auto (“the car bumped my knee and I walked away… now it hurts”)

#3) 34yo M with forearm pain s/p fall off of ladder


Pathology Cascade: Incr osseofascial compartment pressure from local trauma / soft tissue injury (edema, bleeding) => incr interstitial pressure => decr perfusion => (irreversible) nerve and muscle damage

Most Common Site: leg (tibial shaft – #1); forearm (#2); hand; foot; thigh; any site where skeletal muscle is covered by fascia is a possibility

Most Common Patient: Male; less than 35yo

Causes: fracture, crush injury, GSW, contusion, tight splint/cast, IV infiltration, burn, arterial injury, snakebite, nephrotic syndrome

Why it’s challenging: can present w/ vague sxs / exam

Why we care: loss of function / limb


-4 leg compartments

leg compartments

-3 forearm compartments

arm compartments

**Image credit:

Clinical Pearls // Management

Time is muscle! Time to dx is most important prognostic factor; serial exams are your friend, however understand exam isn’t perfect

Pain out of proportion/rest pain is usually first symptom (few clinical entities cause this: mesenteric ischemia, deep soft tissue infection, AAA, biliary tract obstruction, bowel obstruction, pancreatitis, stomach/bowel perforation, MI, vascular occlusion, malignant otitis externa)

not always present or easy to assess (neuropathy, AMS, intubated, polytrauma, young child, unreliable exam)

-important not to treat pain out of proportion to exam as someone opiate seeking

-Most sensitive finding: pain w/ passive stretch; other P’s of compartment syndrome we learned are late findings
(The 6 P’s: pain, paresthesia, pallor, paralysis, pulselessness, poikilothermia)

Difficult to diagnose in children, thus typically delayed; consider in pt w/ proper context + restlessness / rising opioid requirement (see reference 14 for extended discussion)

-No difference in incidence b/t open vs closed fractures; can develop w/out fracture!!

4-8 hours is commonly cited cut-off for when irreversible ischemic changes begin to occur (controversial)

-Work-up: XR as indicated; intracompartmental pressure measurements – w/in 5cm of fx site or area of maximal swelling (Stryker, NIRS) for low/medium risk pts; clinical dx in high-risk pts

-Call Gen Surg/Ortho immediately; remove / loosen dressing/splint/cast, elevate extremity, reduce fracture as appropriate

-Usually it is the surgical service doing the intracompartmental pressure measurement; if working in setting without surgical backup, important to know how to do it (

Emergent fasciotomy: clinical dx or compartment pressures 30-45 mm Hg (exact # controversial and test w/ limitations – see reference 4) / compartment pressures within 30 mm Hg of DBP (delta P); controversial if late identification of compartment syndrome



References // Further Reading

















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