Diferencia entre revisiones de «Compartment syndrome»
(Major update: delta pressure criteria, 6 Ps with clinical pearls, fasciotomy timing, obtunded patient considerations, medicolegal note, references with PMIDs) |
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*Increased pressure within a closed fascial compartment compromising perfusion to muscles and nerves | *Increased pressure within a closed fascial compartment compromising perfusion to muscles and nerves | ||
*'''Surgical emergency''' — irreversible damage begins within '''6-8 hours''' of ischemia | *'''Surgical emergency''' — irreversible damage begins within '''6-8 hours''' of ischemia | ||
*Most common location: | *Most common location: anterior compartment of the leg (tibia fractures) | ||
*Causes: | *Causes: | ||
** | **Fractures (most common — especially tibia, forearm, supracondylar humerus in children) | ||
**Crush injuries, reperfusion injury after vascular repair | **Crush injuries, reperfusion injury after vascular repair | ||
**Burns (circumferential), tight casts/splints/dressings | **Burns (circumferential), tight casts/splints/dressings | ||
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**IV/IO infiltration | **IV/IO infiltration | ||
*Normal tissue pressure: 0-8 mmHg | *Normal tissue pressure: 0-8 mmHg | ||
* | *Ischemia begins when compartment pressure exceeds capillary perfusion pressure | ||
==Clinical Features== | ==Clinical Features== | ||
* | *The 6 P's (pain is earliest and most reliable; pulselessness is latest): | ||
** | **Pain — out of proportion to exam (most sensitive early finding) | ||
** | **Pain with passive stretch of muscles in affected compartment (most sensitive exam finding) | ||
** | **Pressure — tense, firm compartment on palpation | ||
** | **Paresthesias — indicates nerve ischemia | ||
** | **Paralysis — late finding; indicates significant ischemia | ||
** | **Pulselessness — very late finding; presence of pulses does NOT exclude compartment syndrome | ||
* | *Key pearls: | ||
** | **Increasing analgesic requirements should raise suspicion | ||
**Normal pulses and capillary refill do NOT rule out compartment syndrome | **Normal pulses and capillary refill do NOT rule out compartment syndrome | ||
**'''Obtunded, intubated, or pediatric patients''' cannot report pain — maintain '''high index of suspicion''' | **'''Obtunded, intubated, or pediatric patients''' cannot report pain — maintain '''high index of suspicion''' | ||
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==Evaluation== | ==Evaluation== | ||
===Clinical Diagnosis=== | ===Clinical Diagnosis=== | ||
* | *Compartment syndrome is primarily a CLINICAL diagnosis | ||
*Serial examinations are essential | *Serial examinations are essential | ||
*'''Do not delay fasciotomy for pressure measurement''' if clinical picture is clear | *'''Do not delay fasciotomy for pressure measurement''' if clinical picture is clear | ||
===Compartment Pressure Measurement=== | ===Compartment Pressure Measurement=== | ||
* | *Indicated when clinical exam is unreliable (obtunded, pediatric, equivocal exam) | ||
*Methods: Stryker needle (most common in ED), arterial line transducer | *Methods: Stryker needle (most common in ED), arterial line transducer | ||
* | *Absolute pressure >30 mmHg: concerning | ||
* | *Delta pressure (diastolic BP minus compartment pressure) <30 mmHg: indicates need for fasciotomy<ref>McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures: the pressure threshold for decompression. ''J Bone Joint Surg Br''. 1996;78(1):99-104. PMID 8898137</ref> | ||
*'''Delta pressure is more reliable than absolute pressure''' (accounts for patient's perfusion status) | *'''Delta pressure is more reliable than absolute pressure''' (accounts for patient's perfusion status) | ||
*Measure | *Measure all compartments in the affected extremity (leg has 4: anterior, lateral, deep posterior, superficial posterior) | ||
===Labs=== | ===Labs=== | ||
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===Immediate=== | ===Immediate=== | ||
*'''Remove all circumferential dressings, casts, and splints''' immediately | *'''Remove all circumferential dressings, casts, and splints''' immediately | ||
*Keep extremity | *Keep extremity at heart level (elevation may decrease arterial perfusion; dependent position worsens edema) | ||
* | *Avoid hypotension — maintain adequate perfusion pressure | ||
* | *IV fluid resuscitation if rhabdomyolysis | ||
===Fasciotomy=== | ===Fasciotomy=== | ||
* | *Definitive treatment — emergent surgical consultation | ||
* | *Four-compartment fasciotomy for lower leg | ||
*Delay >6-8 hours: significantly increased risk of permanent neuromuscular damage, amputation | *Delay >6-8 hours: significantly increased risk of permanent neuromuscular damage, amputation | ||
*'''Do NOT delay for imaging''' if diagnosis is clinically apparent | *'''Do NOT delay for imaging''' if diagnosis is clinically apparent | ||
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==Disposition== | ==Disposition== | ||
* | *All suspected cases require admission and emergent orthopedic/surgical consultation | ||
*ICU if [[rhabdomyolysis]] or hemodynamic instability | *ICU if [[rhabdomyolysis]] or hemodynamic instability | ||
* | *Missed compartment syndrome is a significant medicolegal risk | ||
==See Also== | ==See Also== | ||
Revisión actual - 09:31 22 mar 2026
Background
- Increased pressure within a closed fascial compartment compromising perfusion to muscles and nerves
- Surgical emergency — irreversible damage begins within 6-8 hours of ischemia
- Most common location: anterior compartment of the leg (tibia fractures)
- Causes:
- Fractures (most common — especially tibia, forearm, supracondylar humerus in children)
- Crush injuries, reperfusion injury after vascular repair
- Burns (circumferential), tight casts/splints/dressings
- Hemorrhage (anticoagulation), rhabdomyolysis
- Envenomation (snakebite)
- IV/IO infiltration
- Normal tissue pressure: 0-8 mmHg
- Ischemia begins when compartment pressure exceeds capillary perfusion pressure
Clinical Features
- The 6 P's (pain is earliest and most reliable; pulselessness is latest):
- Pain — out of proportion to exam (most sensitive early finding)
- Pain with passive stretch of muscles in affected compartment (most sensitive exam finding)
- Pressure — tense, firm compartment on palpation
- Paresthesias — indicates nerve ischemia
- Paralysis — late finding; indicates significant ischemia
- Pulselessness — very late finding; presence of pulses does NOT exclude compartment syndrome
- Key pearls:
- Increasing analgesic requirements should raise suspicion
- Normal pulses and capillary refill do NOT rule out compartment syndrome
- Obtunded, intubated, or pediatric patients cannot report pain — maintain high index of suspicion
Differential Diagnosis
- Deep vein thrombosis
- Cellulitis / necrotizing fasciitis
- Fracture pain
- Peripheral vascular injury
- Neuropraxia
- Rhabdomyolysis without compartment syndrome
- Acute arterial occlusion
Evaluation
Clinical Diagnosis
- Compartment syndrome is primarily a CLINICAL diagnosis
- Serial examinations are essential
- Do not delay fasciotomy for pressure measurement if clinical picture is clear
Compartment Pressure Measurement
- Indicated when clinical exam is unreliable (obtunded, pediatric, equivocal exam)
- Methods: Stryker needle (most common in ED), arterial line transducer
- Absolute pressure >30 mmHg: concerning
- Delta pressure (diastolic BP minus compartment pressure) <30 mmHg: indicates need for fasciotomy[1]
- Delta pressure is more reliable than absolute pressure (accounts for patient's perfusion status)
- Measure all compartments in the affected extremity (leg has 4: anterior, lateral, deep posterior, superficial posterior)
Labs
- CK (elevated in rhabdomyolysis)
- BMP (monitor renal function, hyperkalemia)
- Urinalysis (myoglobinuria)
Management
Immediate
- Remove all circumferential dressings, casts, and splints immediately
- Keep extremity at heart level (elevation may decrease arterial perfusion; dependent position worsens edema)
- Avoid hypotension — maintain adequate perfusion pressure
- IV fluid resuscitation if rhabdomyolysis
Fasciotomy
- Definitive treatment — emergent surgical consultation
- Four-compartment fasciotomy for lower leg
- Delay >6-8 hours: significantly increased risk of permanent neuromuscular damage, amputation
- Do NOT delay for imaging if diagnosis is clinically apparent
- Wound typically left open with delayed primary closure or skin grafting at 48-72 hours
Post-Fasciotomy Monitoring
- Serial CK, renal function, electrolytes
- Monitor for reperfusion injury (hyperkalemia, metabolic acidosis, rhabdomyolysis)
- Broad-spectrum antibiotics if contaminated wound
Disposition
- All suspected cases require admission and emergent orthopedic/surgical consultation
- ICU if rhabdomyolysis or hemodynamic instability
- Missed compartment syndrome is a significant medicolegal risk
See Also
References
- ↑ McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures: the pressure threshold for decompression. J Bone Joint Surg Br. 1996;78(1):99-104. PMID 8898137
- Via AG, et al. Acute compartment syndrome. Muscles Ligaments Tendons J. 2015;5(1):18-22. PMID 25878982
- Shadgan B, et al. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma. 2008;22(8):581-587. PMID 18758292
- Schmidt AH. Acute compartment syndrome. Orthop Clin North Am. 2016;47(3):517-525. PMID 27241376