eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Compartment Syndrome, Extremity: Treatment & Medication

Author: Richard Paula, MD, Director of Research, Assistant Professor of Emergency Medicine, University of South Florida
Contributor Information and Disclosures

Updated: Dec 10, 2008

Treatment

Prehospital Care

Compartment syndrome (CS) can develop rapidly after an arterial injury. Therefore, speed of transport is essential. Perform only the necessary lifesaving procedures in the field if CS is suspected.

Emergency Department Care

Time is of the essence in diagnosing and treating compartment syndrome. Irreversible nerve damage begins after 6 hours of intracompartmental hypertension. If CS is suspected, pressure measurements and appropriate consultation must be performed quickly.

  • Many cases of CS are due to trauma. Follow advanced trauma life support (ATLS) guidelines to stabilize the patient before attempting to address CS.
  • Ischemic injury is the basis for CS. Additional oxygen should be administered because it slightly increases partial pressure of oxygen (PO2).
  • Keeping extremities level with the body decreases limb mean arterial pressure without changing intracompartmental pressure.
  • Do not elevate the affected extremity. Styf and Wiger (1998) measured, after an elevation of 35 cm, a decrease in the mean arterial perfusion pressure of 23 mm Hg and no change in intracompartmental pressure.6
    • Intravenous (IV) hydration is essential, hypovolemia will worsen ischemia.
  • Fasciotomy remains the definitive therapy for CS because of its well-documented, limb-saving results.
    • Recently, timing and use of fasciotomy have been questioned. Fasciotomy extends hospital stay and changes a closed injury to an open injury, greatly increasing the chance of infection.
    • As mentioned previously, debate exists regarding the threshold for fasciotomy. A number of authors recommend 30 mm Hg, while others cite 45 mm Hg. Still others urge prophylactic fasciotomy at normal pressures to prevent CS.
    • Convincing evidence reflects that debate should center on delta-p. Delta-p is a measure of perfusion pressure (diastolic blood pressure minus intracompartmental pressure). Originally used in dogs, delta-p measurements of less than 30 mm Hg were used by McQueen (1996) for fasciotomy.7 As a result, several patients with intracompartmental pressures of 40 mm Hg or greater were observed because the delta-p was greater than 30 mm Hg. Criteria were used in 116 patients without sequelae. The converse also is true, since patients with intracompartmental pressures less than 30 mm Hg but with high delta-p values have developed CS.
  • A special note about envenomations: Recent studies have confirmed previously postulated theories that myonecrosis associated with compartment syndrome after envenomation is multifactorial and that fasciotomy may not prevent myonecrosis. Myonecrosis is thought to be due to a direct toxic effect of the venom and the inflammatory response. Therefore, these patients should be aggressively treated with antivenom if available, as this has been shown to decrease limb hypoperfusion.

Consultations

  • General surgeon
  • Orthopedic surgeon
  • Vascular surgeon
  • Toxicologist

Medication

Some authors have advocated the use of mannitol for CS. While its use in rhabdomyolysis is well documented, its use in acute CS is new. More recently, Daniels and Reichman treated an Israeli soldier who developed CS with mannitol.8 After resolution, he was discharged without a fasciotomy. Unfortunately, intracompartmental pressures were not measured, since the diagnosis was based on limb circumference and nerve conduction studies. Further investigation is warranted in this area.

Hyperbaric oxygen (HBO) therapy is a logical choice for CS because it addresses the primary concern of ischemic injury. HBO has many beneficial effects. It reduces edema through oxygen-induced vasoconstriction while maintaining oxygen perfusion and supports tissue healing in a similar mechanism by allowing oxygen delivery when perfusion pressure is low. Reperfusion injury following CS often is voiced as an argument against HBO. However, HBO actually protects against reperfusion injury.

Bouachour performed a well-controlled randomized study with 31 patients following crush injury and demonstrated significant increase in complete healing (p <0.0005) with HBO. Wattel et al have given an appraisal of the current literature regarding HBO therapy for CS and justifiably concluded that studies demonstrate HBO effectiveness in improving wound healing, reducing amputation rate, and lowering surgical procedure rate.9

Although HBO currently is only adjunctive therapy because of its limited availability, it should not be ignored. It may extend treatment duration and it may not reverse the CS etiology, but it has been shown to be beneficial.

More on Compartment Syndrome, Extremity

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Multimedia: Compartment Syndrome, Extremity
References
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References

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Further Reading

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Keywords

compartment syndrome extremity, CS, compartmental syndrome, Volkmann contracture, Volkmann's contracture, intracompartmental pressure, extremity pain, perfusion pressure, capillary perfusion pressure, CPP, venous pressure, long bone fractures, vascular injury, ischemic injury, fasciotomy, paraesthesia, limb pain, high-energy trauma, penetrating injuries, venous injury, crush injuries, tetany, vigorous exercise, seizures, stationary bicycle use, horseback riding, burns, intraarterial injection, envenomation, decreased serum osmolarity, nephrotic syndrome, infiltrated infusion, hemorrhage, military antishock trousers, MAST

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Contributor Information and Disclosures

Author

Richard Paula, MD, Director of Research, Assistant Professor of Emergency Medicine, University of South Florida
Richard Paula, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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