8-30
What Not To Do:
Do not perform under the following circumstances:
Local infection along the proposed needle entrance tract (e.g., overlying cellulitis, periarticular
infection)
Uncooperative patient, especially if unable to keep the joint immobile throughout procedure
Difficult to identify bony landmarks
A poorly accessible joint space, as in hip aspiration in the obese patient
Inability to demonstrate a joint effusion on physical examination, except when septic arthritis is strongly
suspected.
Procedure: Compartment Syndrome Management
LTC Winston Warme, MC, USAWhat: Relieve pressure of compartment syndrome by fasciotomy.
When: Compartment Syndrome (CS) is a condition in which structures such as muscles, vessels and nerves
are constricted within a tight fascial compartment. It results when internal or external pressure reduces capillary
perfusion below the level necessary for tissue viability in a closed fascial space or muscle compartment. This
is most common in the leg secondary to blunt trauma (but may occur in the arms) and may be due to crush
injury, muscle rupture and burns. On exam, the compartments will be tense in comparison to the other side. The
patient will complain of pain, especially with passive movement joints distal to the injury. The other Ps (pallor,
paresthesia and pulselessness) are late findings and only strengthen the diagnosis already made.
What You Need: IV fluids, an IV infusion set, splinting material, medications for pain, antibiotics, tetanus
prophylaxis, bandages for open wounds, a minor surgical set (scalpel, blades, tissue forceps, retractors, scis-
sors), +/- a urinary catheter set.
What To Do:
- Identify a suspected compartment syndrome (CS) based on patient history.
NOTE: There are three main physiological reactions that can cause compartment syndromes: increased
accumulation of fluid (bleeding, e.g., a closed tibia fracture), decreased volume (constriction of compartment),
or external compression (crush injury).
a. Fractures: closed or open.
b. Severe contusion with no fracture, (e.g., s/p kicked in the leg in a soccer game).
c. Recently applied splint, cast or bandage.
d. Injury to a major blood vessel may produce CS: bleeding in the compartment, partial occlusion of
the artery secondary to spasm/initial tear with inadequate collateral circulation, or postischemic
swelling without restoration of circulation (delayed more than 6 hours).
e. Extreme exertion - long distance running with improper training. Different from the chronic condition
of exertional compartment syndrome that may require elective release, but is not an emergency. This
presents with recurrent mild pain in the anterior or lateral compartments of lower leg, sometimes with
a foot drop or neurologic signs.
f. Burns: Decrease compartment size with massive edema; coalesces the skin, subcutaneous tissue &
fascia into one tight, constricting eschar; underlying compression of nerves/muscles. May require
escharotomy (see Burns chapter).
g. Other causes: anticoagulant therapy, arterial puncture, hemophilia, infiltration of IV fluid, and snake
bites. - Identify a suspected compartment syndrome based on signs and symptoms.
a. The most important symptom if an impending CS is pain that is out of proportion to the primary
problem or injury.
b. The 6 Ps: Pressure - the earliest finding; swollen, palpably tense compartment. Pain on stretch -