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passive movement of the digits may produce pain in the involved ischemic muscles. Paresis - muscle
weakness due to primary nerve involvement, muscle ischemia, or guarding secondary to pain.
Paresthesia or anesthesia - a late physical finding in a conscious and cooperative patient is a sensory
deficit. Must perform a nerve (sensory) exam to find affected compartment. Pulses present - peripheral
pulses are palpable in 90% patients. Pallor - capillary refill is routinely present
- Rule out other probable causes because of morbidity of treatment (fasciotomy).
a. Diagnosis of compartment syndrome: Peripheral pulses intact R/O arterial injury. Nerve injuries cause
little pain.
b. Diagnosis for arterial injury - usually absent pulses, poor skin color and decreased skin temperature.
c. Diagnosis for nerve damage (neurapraxia): Remarkable paresis or paresthesia, nerve damage
(neurapraxia) associated with a fracture or contusion. - Assess the patient
a. Monitor and maintain vital signs and urinary output to minimize hypotension.
NOTE: Insert a urinary catheter as necessary.
b. Administer suitable medications: to alleviate pain and anxiety (see Procedure: Pain Assessment and
Control), antibiotic therapy and tetanus prophylaxis for open wounds (see Burns).
c. Monitor the patient for crush syndrome (similar to Compartment Syndrome, but also suffer distal pulse
and neurological damage) and manage accordingly. May need kidney support and fasciotomy. - Decompress the affected compartments. This is a skill that should be developed in medlab or during
ATLS training. Trying this out when you have never done it in a lab or in the OR is not recommended. Do
your training beforehand and be ready for this contingency.
a. Loosen/remove volume-restricting plaster casts and circular dressings. Splitting and spreading a
plaster cast may result in a 65% decrease in intra-compartmental pressure. Keep the limb at heart
level. Do not elevate it as this can decrease perfusion. If symptoms of neurologic deficit persist more
than 1 hour after cast splitting, the cast and all circular dressings must be removed and the limb
re-examined.
b. There are no satisfactory nonsurgical methods for treating compartment syndromes. Surgical decom-
pression, which allows the volume of the compartments to increase, is the primary means of relieving
pressure.
c. Evacuate all cases of suspected Compartment Syndrome. If evacuation is not possible, proceed as
below.
d. Treatment: Adequate decompression of the muscular compartments with scissors (fasciotomies).
Incise skin 12 centimeters along the anterolateral and posteromedial sides of the leg to allow for
release of the anterior and lateral compartments and superficial and deep compartments of the leg,
respectively. In the arm, two 5 cm vertical incisions are placed on the dorsum of the hand between the
index and middle metacarpals and the ring and small metacarpals. The fascia is then split. 20 cm
incisions are placed on the volar and dorsal aspects of the forearm to release the underlying fascia
under direct visualization. Release of the carpal tunnel is also needed on the volar aspect of the wrist,
but due to possible damage to the median nerve, should not be attempted without seeing it done
before.
e. Do not close the skin. May need to perform additional surgery. - Perform postoperative care
a. Leg and arm wounds are cared for in the routine manner (see Procedure: Skin Mass Removal).
b. Without fractures: Closure in a week (delayed primary closure, if possible) with or without skin grafting.
Necrotic muscle is debrided once or twice a week until a satisfactory granulation bed is present (see
Procedure: Wound Debridement).
CAUTION: Skin grafting or closure prior to this may lead to infection and the need for subsequent
amputation. Prevent development of contractures: the ankle is splinted in the neutral position and the
forearm is splinted in the position of function (holding a beer can).
c. Fracture present: Closed fractures require referral for fixation. Open fractures require referral for
fixation.
d. If renal insufficiency develops, reduce fluid administration and evacuate the patient. - Record all treatment given.