eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Compartment Syndrome: Treatment & Medication
Updated: Mar 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
Exertional compartment syndrome initially is treated differently from the trauma-induced form. A trial of conservative treatment may result in resolution of symptoms in exertional compartment syndrome. The conservative treatment mainly involves a decrease in activity or load to the affected compartment. The activity level gradually is increased, depending on the symptomatology. Aquatic exercises, such as running in water, can improve mobility and strength without unnecessarily loading the affected compartment. Massage and stretching exercises also have been shown to be effective, according to Hutchinson and Ireland.16
The patient who undergoes fasciotomy requires a physical therapy program to regain function. Postoperative care and rehabilitation is just as important as the procedure itself. During the immediate postoperative period, weight bearing is limited, and assistive devices (eg, crutches) are needed. Within a few days, and with adequate pain control, the use of crutches can be discontinued. The rehabilitation program then involves range of motion (ROM) and flexibility exercises involving the muscles of the affected compartment. Adjacent joints need to be exercised to maintain their normal ROM.
Once the patient is able to ambulate with a normalized gait pattern, a program of graduated resistive exercises (depending on the person's regular activities or work) is initiated. In the case of athletes, sports-specific exercises are started with the intention of returning to a regular athletic schedule. Cross training is also beneficial for these athletes. Activities such as swimming, pedal exercises, water jogging, or running help athletes to regain muscle strength and flexibility without loading the affected compartment.
Occupational Therapy
With surgical intervention for decompression, occupational therapy consultation should be considered early in the postoperative period for assessment of appropriate treatment and of the patient's deficits with regard to activities of daily living (ADL), as well as for instruction in the use of any necessary assistive device(s).
Medical Issues/Complications
Nonsteroidal anti-inflammatory drugs (NSAIDs) also have been shown to be helpful in relieving the discomfort of compartment syndrome.
Surgical Intervention
When compartment pressures are elevated, especially in acute settings, prompt surgical evaluation should be performed, since elevated pressures can, over a prolonged period, cause irreversible damage.17,18 The exact pressure at which a fasciotomy may be performed is somewhat debatable.4,6,8,9
Consultations
An orthopedic surgeon needs to be consulted early in cases in which acute compartment syndrome is suspected. With the chronic picture, if the initial intervention of decreasing the patient's activity level is not helpful or possible, then surgical decompression is necessary.
Other Treatment
Many authors advocate the use of hyperbaric oxygen therapy (HBO) for treatment of compartment syndrome.
Related eMedicine topics:
Hyperbaric Oxygen Therapy [Clinical Procedures]
Hyperbaric Oxygen Therapy [Plastic Surgery]
Hyperbaric Oxygen
Medication
Opioids, nonopioids, and NSAIDs can be used for pain management in compartment syndrome.19 Side effects and patient profiles should be considered when choosing medications. Acetaminophen can result in liver damage. Narcotics can produce gastrointestinal distress, constipation, and sedation, and they have addictive potential. NSAIDs can result in gastrointestinal upset, gastrointestinal bleeding, renal damage, and impaired coagulation.
Analgesic agents
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
Acetaminophen (Tylenol, FeverAll, Aspirin Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
500-1000 mg PO q6h prn
Pediatric
Not established
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen (APAP) is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose
Opioid analgesics
These medications provide control of moderate to severe pain.
Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tabs PO q6h prn
Pediatric
Not established
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tabs contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Naproxen (Naprosyn, Aleve, Naprelan, Anaprox)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO bid prn
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Cyclooxygenase-2 inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with cyclooxygenase-2 (COX-2) inhibitors than it is with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme; induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult
200-400 mg PO qd or divided bid
Pediatric
Not established
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease plasma concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention, severe heart failure, and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results
More on Compartment Syndrome |
| Overview: Compartment Syndrome |
| Differential Diagnoses & Workup: Compartment Syndrome |
 Treatment & Medication: Compartment Syndrome |
| Follow-up: Compartment Syndrome |
| References |
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References
Qvarfordt P, Christenson JT, Eklof B, et al. Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome. Clin Orthop. Oct 1983;(179):284-90. [Medline].
Amendala A, Rorabeck CH. Chronic exertional compartment syndrome. In: Welsh RP, Shepard RJ, eds. Current Therapy in Sports Medicine. 1985. Toronto, Canada: BC Decker; 250-2.
Blackman P, Bradshaw C, Crossley K. Chronic exertional compartment syndrome in the lower leg. A comparison of treatment options and outcome. International Conference of Science and Medicine in Sports, Brisbane, Australia. 1994;56-7.
Blackman PG. A review of chronic exertional compartment syndrome in the lower leg. Med Sci Sports Exerc. Mar 2000;32(3 Suppl):S4-10. [Medline].
Eisele SA, Sammarco GJ. Chronic exertional compartment syndrome. Instr Course Lect. 1993;42:213-7. [Medline].
Howard JL, Mohtadi NG, Wiley JP. Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg. Clin J Sport Med. Jul 2000;10(3):176-84. [Medline].
Liem NR, Bourque PR, Michaud C. Acute exertional compartment syndrome in the setting of anabolic steroids: an unusual cause of bilateral footdrop. Muscle Nerve. Jul 2005;32(1):113-7. [Medline].
Mouhsine E, Garofalo R, Moretti B, et al. Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc. Feb 2006;14(2):193-7. [Medline].
Schepsis AA, Martini D, Corbett M. Surgical management of exertional compartment syndrome of the lower leg. Long-term followup. Am J Sports Med. Nov-Dec 1993;21(6):811-7; discussion 817. [Medline].
Wallensten R, Karlsson J. Histochemical and metabolic changes in lower leg muscles in exercise- induced pain. Int J Sports Med. Aug 1984;5(4):202-8. [Medline].
Detmer DE, Sharpe K, Sufit RL, et al. Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med. May-Jun 1985;13(3):162-70. [Medline].
Bleicher RJ, Sherman HF, Latenser BA. Bilateral gluteal compartment syndrome. J Trauma. Jan 1997;42(1):118-22. [Medline].
Arato E, Kurthy M, Sinay L, et al. Pathology and diagnostic options of lower limb compartment syndrome. Clin Hemorheol Microcirc. 2009;41(1):1-8. [Medline].
Reach JS Jr, Amrami KK, Felmlee JP, et al. The compartments of the foot: a 3-tesla magnetic resonance imaging study with clinical correlates for needle pressure testing. Foot Ankle Int. May 2007;28(5):584-94. [Medline].
Yu JS, Habib P. MR imaging of urgent inflammatory and infectious conditions affecting the soft tissues of the musculoskeletal system. Emerg Radiol. Jan 9 2009;[Medline].
Hutchinson MR, Ireland ML. Common compartment syndromes in athletes. Treatment and rehabilitation. Sports Med. Mar 1994;17(3):200-8. [Medline].
Pollak AN. Use of negative pressure wound therapy with reticulated open cell foam for lower extremity trauma. J Orthop Trauma. Nov-Dec 2008;22(10 Suppl):S142-5. [Medline].
Brey JM, Castro MD. Salvage of compartment syndrome of the leg and foot. Foot Ankle Clin. Dec 2008;13(4):767-72. [Medline].
Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. Jan 2009;102(1):3-11. [Medline].
Edmundsson D, Toolanen G, Sojka P. Chronic compartment syndrome also affects nonathletic subjects: a prospective study of 63 cases with exercise-induced lower leg pain. Acta Orthop. Feb 2007;78(1):136-42. [Medline].
Frezza EE. The lithotomy versus the supine position for laparoscopic advanced surgeries: a historical review. J Laparoendosc Adv Surg Tech A. Apr 2005;15(2):140-4. [Medline].
Frink M, Klaus AK, Kuther G, et al. Long term results of compartment syndrome of the lower limb in polytraumatised patients. Injury. May 2007;38(5):607-13. [Medline].
Phillips JH, Mackinnon SE, Beatty SE, et al. Vibratory sensory testing in acute compartment syndromes: a clinical and experimental study. Plast Reconstr Surg. May 1987;79(5):796-801. [Medline].
Rasul AT Jr, Gustilo R. Compartmental syndrome. In: Gustilo RB, ed. Fractures and Dislocations. vol 2. St Louis, Mo: Mosby-Year Book; 1993:1251-8.
Snyder BJ, Oliva A, Buncke HJ. Calcific myonecrosis following compartment syndrome: report of two cases, review of the literature, and recommendations for treatment. J Trauma. Oct 1995;39(4):792-5. [Medline].
Steinberg BD. Evaluation of limb compartments with increased interstitial pressure. An improved noninvasive method for determining quantitative hardness. J Biomech. Aug 2005;38(8):1629-35. [Medline].
Further Reading
Keywords
compartment syndrome, fasciotomy, anterior compartment syndrome, compartmental syndrome, acute compartment syndrome, exertional compartment syndrome, compartment pressure, intracompartmental pressure
