Compartment syndrome remains a challenging problem for the
clinicians. The diagnosis of compartment syndrome may be not that easy, and it
may be confusing or not straight forward. In general, a high index of suspicion
is necessary for the diagnosis of compartment syndrome. If the patient has pain
more than what is expected from surgery or from an injury, or if there is an
increase in narcotic requirements, and the patient has tense swelling and pain,
with the pain increasing with passive stretch of the compartment muscles, then
this is an indication that the patient may be suffering from a compartment
syndrome. You like to see these patients and treat them during the impending
stage, not during the well-established stage. You want to diagnose compartment
syndrome early before the muscle dies, which will cause weakness to the muscle
function. Diagnosis and treatment for compartment syndrome should be done
early. Tight dressings should be removed. If there is a cast, the cast should
be split or removed and examine the extremity. The extremity should be examined
for pain and swelling. Do not wait for the classic, old teaching of the 5 P’s
to appear as these findings are considered to be late findings. Do not wait for
the paresthesia, the pulselessness, the pallor, and the paralysis. These
represent irreversible damage to the muscles and the nerves. The patient may
have good pulses even in the presence of compartment syndrome. Pulses will be
normal in the presence of compartment syndrome. The combination of pain and
swelling, and pain with passive stretch, is an indication of compartment
syndrome. If you suspect compartment syndrome and you are not sure of the
diagnosis, then measure the pressure of the compartments. If the compartment
pressures is greater than 30mmHg or within 30mmHg of the diastolic pressure,
then this is an indication that the patient is probably going in the direction
of compartment syndrome and an immediate fasciotomy should be considered.
Compartment syndrome can occur in any anatomical part in the upper extremity or
the lower extremity. The most commonly involved anatomic part is the lower leg,
and the most commonly involved compartment in the lower leg is the anterior
compartment. The anterior muscle compartment of the lower leg contains the deep
peroneal nerve. The deep peroneal nerve gives sensation in the first web space.
When you examine the patient for compartment syndrome, check for numbness of
the first web space. The elevated pressure affects the microcirculation and the
perfusion of the tissues. The muscle compartment needs to be released within 6
hours. Irreversible damage can occur after 8 hours. Formal release of the
muscle compartments in the operating room under general anesthesia continues to
be the procedure of choice. You may not be able to do formal release of the
muscle compartments due to being called to a patient in the intensive care
unit, in the emergency room, or the patient may be in the floor. There may not
be enough time to do the procedure in the operating room due to the patient’s
condition or operating room conditions. Bedside fasciotomy under conscious
sedation and local anesthesia was developed in order to avoid delay in
fasciotomy surgery. Time is critical for the release of compartment syndrome.
It is advisable to do fasciotomy early. If fasciotomy is done within 3-4 hours
the damage is reversible. At 6 hours there will be variable muscle damage.
Delay in fasciotomy can occur due to medical comorbidities, need clearance for
general anesthesia and patient may be on anticoagulation (need to reverse and
control that); polytrauma patient, need time for resuscitation; or recent oral
intake, fluids or solid food. It is probably not easy to guess and to predict
when the exact onset of increased pressure of compartment syndrome occurred in
the extremity. Bedside fasciotomy is a good option for patients with delayed
presentation or in those with anticipated time delay. The procedure can be done
in the ICU, the ER, or on the floor. The patient can be given conscious
sedation. Give the appropriate doses and some doses may be appropriate for a
normal sized, healthy adult, but may not be appropriate for patients with sleep
apnea or other medical comorbidities. You can also use 1% lidocaine without
epinephrine to infiltrate the marked skin and subcutaneous tissue incision
line. Bedside fasciotomy can be done for the arm, the forearm, hand, thigh,
lower leg, and foot. It is good to train a diverse group of health
professionals in how to do bedside fasciotomy. There are four compartments in
the leg: the anterior, lateral, superficial, posterior, and deep posterior
compartments usually are released through two incisions, one medial and one
lateral. 1% lidocaine is used without epinephrine at the marked skin incision
line. The lateral incision is made halfway between the tibia and the fibula for
release of the anterior and lateral compartments. When you release the lateral
compartment, avoid injury to the superficial peroneal nerve. The medial
incision is made 2 cm posterior to the tibia. You can also do the procedure
through one lateral incision.
