Acute Compartment Syndrome Clinical Presentation

Updated: Jan 17, 2017
  • Author: Abraham T Rasul, Jr, MD, FAAPMR, FCCP; Chief Editor: Consuelo T Lorenzo, MD  more...
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Presentation

History

Patients with compartment syndrome typically present with pain whose severity appears out of proportion to the injury. The pain is often described as burning. The pain is also deep and aching in nature and is worsened by passive stretching of the involved muscles. The patient may describe a tense feeling in the extremity. Pain, however, should not be a sine qua non of the diagnosis. In severe trauma, such as an open fracture, it is difficult to differentiate between pain from the fracture and pain resulting from increased compartment pressure.

Paresthesia or numbness is an unreliable early complaint [10] ; however, decreased 2-point discrimination is a more reliable early test and can be helpful to make the diagnosis. Botte and Gelberman reported that 4 of 9 awake patients with compartment pressures higher than 30 mm Hg had median nerve 2-point discrimination of more than 1 cm. [15] Correlation has also been reported between diminished vibration sense (256 cycles/s) and increasing compartment pressure. Importantly, note that these symptoms assume a conscious patient who did not suffer any additional injury that hinders sensory input (eg, spinal cord injury). In young children, the ability to gather a history of complaints is limited.

Determine the mechanism of injury. High-velocity injuries are particularly worrisome, as are long-bone fractures and crush injuries. Penetrating injuries (eg, gunshot wounds, stabbings) can cause arterial injury, which can quickly lead to compartment syndrome. Venous injury may also cause compartment syndrome, however, so the clinician should not be misled by the presence of palpable pulses.

Anticoagulation therapy and bleeding disorders (eg, hemophilia) significantly increase the likelihood of compartment syndrome. Remember to ask if patients are anticoagulated for any reason. Compartment syndrome requiring fasciotomy has been observed after simple venipuncture in an anticoagulated patient.

Vigorous exertion may lead to compartment syndrome. Compartment syndrome has been found in soldiers and athletes without any trauma. This can be acute or chronic, with acute compartment pressures as high as those found in severe trauma. If compartment syndrome is suspected, check intracompartmental pressure, even in the absence of any trauma history. [52]

Hand compartment syndrome

Compartment syndrome in the hand most often occurs following iatrogenic injury in a patient who is obtunded in an intensive care unit. Symptoms may be nonspecific when compared with those in other cases of compartment syndrome. Early recognition of this complication is based on physical examination and a high index of suspicion. Compartment syndrome in the hand, unlike cases elsewhere in the body, does not cause abnormalities in the sensory nerves, as no nerves are found within the compartments.

Consider the diagnosis when nonspecific aching of the hand, increased pain, loss of digital motion, and continued swelling are present. A tight, swollen hand in an intrinsic minus position—with the digits in metacarpophalangeal (MCP) extension and proximal interphalangeal (PIP) flexion—is highly indicative. Intrinsic tightness becomes evident on examination because motion of the PIP joint becomes dependent on the position of the MCP joint (more PIP motion is possible with MCP flexion than with MCP extension).

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Physical Examination

On physical examination, evidence of trauma and gross deformity should alert the physician to the possibility of a developing compartment syndrome. Comparison of the affected limb to the unaffected limb is useful. Excessively vigorous examination of a tibial fracture should be avoided because this may exacerbate irritation of the deep posterior compartment.

Common symptoms observed in compartment syndrome include a feeling of tightness and swelling. Pain with certain movements, particularly passive stretching of the muscles, is the earliest clinical indicator of compartment syndrome. A patient may report pain with active flexion.

The traditional 5 P's of acute ischemia in a limb (ie, pain, paresthesia, pallor, pulselessness, poikilothermia) are not clinically reliable; they may manifest only in the late stages of compartment syndrome, by which time extensive and irreversible soft tissue damage may have taken place. Peripheral pulses and capillary refill remain normal in most cases of upper extremity acute compartment syndrome.

The most important diagnostic physical finding is a firm, wooden feeling on deep palpation. Bullae may also be seen; however, so-called fracture blisters are common in the absence of compartment syndrome. In cases involving the leg, a soft tissue mass may be noticed as a result of herniation of fat and/or muscle tissue from the fascial defect that is often found in the lower third of the leg. In cases of trauma and gross deformity, a claw-toe deformity might occur; therefore, the patient should be evaluated for such a condition.

If a patient complains of pain, determine whether any neural compromise is present. Sensory nerves tend to be affected before the motor nerves, and selected nerves may be more susceptible than others in the same compartment. For example, in acute anterior lower leg compartment syndrome, the first sign to develop may be numbness between the first 2 toes (superficial peroneal nerve).

Decreased 2-point discrimination is the most consistent early finding, and correlation has also been reported between diminished vibration sense (as measured with a 256 cycle per second tuning fork). If objective evidence of a major sensory deficit, a motor deficit, or loss of peripheral pulse is found, the syndrome is far advanced.

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