Compartment Syndrome

You are the CT1 covering the orthopaedic wards on a night shift. A 30-year old gentleman has had surgery to his right tibia and fibula following a motorcycle accident and is now complaining of pain and numbness in his lower limb and foot. How would you proceed?

Example answer introduction

In this scenario I would be most worried about compartment syndrome. This is a surgical emergency and I would discuss this patient with the on call Orthopaedic Registrar after completing my initial assessment and management. My differential would include acute limb iscahemia, DVT, rhabdomyolysis or inadequate post-operative analgesia.

Initial Assessment and Simultaneous Resuscitation:

​On arrival, manage the patient using the A to E approach according to the Advanced Life Support algorithm.

  • Airway

  • Breathing - O2 saturations, work of breathing - intercostal recession, use of accessory muscles - if any concerns give oxygen

  • Circulation - pulse, blood pressure, central and peripheral capillary refill time, urine output - consider catheterisation, IV access and bloods as above. 

    • Consider IV fluid bolus

  • Disability - AVPU, pupillary response, blood glucose

  • Exposure - look for signs of shock, look for any other clues, BM, temperature

​​

During the acute phase state remember to provide constant reassessment. 

Focused history

  • Allergies

  • Medications – has analgesia been prescribed/given? 

  • Past medical history

  • Last meal

  • Events leading up to this point - i.e. what procedure have they had and when?

Examination

In this case it is EXTREMELY important to remove the patient's cast as the problem could be just that. 

Examine for: 

 

Six P’s – Pain (most important), pallor, paraesthesia, pulselessness, increased pressure and paralysis (late sign)

  • Look for pallor, feel the temperature of the limb, check limb capillary refill time

  • Palpate pulses, use handheld Doppler if available

  • Check limb sensation

  • Assess active and passive range of movement

  • Assess their pain - passive stretch, and usually out of proportion to stimulus

  • If available, measure the intra-compartmental pressures with arterial pressure monitor. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic

Example questions to progress the station

Q1 - What is your differential diagnosis?

  • Compartment syndrome

  • Necrotizing fasciitis

  • Ischemic limb

  • Cellulitis

  • DVT

Q2 - What is compartment syndrome?

 

" Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged."

Q3 - What is your initial management for suspected compartment syndrome?

See below

Immediate management

  • Adequate fluid resuscitation

  • Analgesia according to World Health Organisations pain ladder

  • Elevation of the limb is contraindicated as it decreases arterial flow to the limb – place at heart level. 

  • Escalate to Orthopaedic Registrar

  • Prep for theatre – Bloods, P-Possum score, Anaesthetist, Emergency theatres, Keep nil by mouth 

  • Consent patient for Lower Limb Fasciotomy if able (remember delegated consent is a current area of contention). 

  • Keep patient and any relatives informed

Further investigations

Laboratory tests are often normal and should not delay a return to theatre in this case. If rhabdomyolysis is suspected then the renal function, creatinine kinase, urinalysis, urinary myoglobin should be checked serially as they may indicate developing compartment syndrome. The remaining laboratory tests are performed as part of the pre-operative work-up

Remember to document your findings and management plan and inform the patient/parents.

 Escalation

Compartment syndrome is a surgical emergency. If confirmed, the patient must have a fasciotomy to decompress the muscle compartments within 4-6 hours to allow the microvascular circulation and oxygenation of tissues to normalise. 

Consider discussion with:

  • Orthopaedic Regestrar on call

  • Potentially consultant if Regestrar is unavailable

  • Anaesthetics

  • Theatre staff

Useful Resources

The Pathophysiology, Diagnosis and Current Management of Acute Compartment Syndrome

 
 
 
 
 
 
 
 
Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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