Acute Compartment Syndrome: Beat the Clock, Save the Limb: Diagnosis, Delta P, and Emergency Fasciotomy

In this episode of Hospital Medicine Unplugged, we tackle compartment syndrome—diagnose early, intervene fast, and prevent long-term complications.

We start with the essentials: pain management and serial assessments. The hallmark symptom is pain out of proportion to the injury. Administer analgesics promptly, but adjust based on the severity. For pain refractory to standard treatment, consider regional anesthesia or nerve blocks—but be cautious, as these may mask symptoms and delay diagnosis. Pain with passive stretch and paresthesias are critical early signs.

Next, we focus on diagnosis—it’s all about clinical assessment and intracompartmental pressure (ICP) measurements. In cases where the exam is unreliable (e.g., sedated or unconscious patients), measure ICP. A pressure difference of <30 mmHg between diastolic blood pressure and compartment pressure is a strong indicator for fasciotomy. Remember, serial exams are crucial in high-risk patients—this condition is dynamic.

Now, onto emergent treatment—fasciotomy is the only definitive option. Delays in intervention increase the risk of muscle necrosis, contractures, and permanent disability. Fasciotomy should aim for complete decompression of all affected compartments. Postoperative care includes wound care, infection prevention, and rehabilitation to prevent functional impairment and chronic pain.

For long-term management, focus on rehabilitation. Early physical therapy helps prevent muscle atrophy and joint contractures. Multidisciplinary care involving orthopaedics, plastic surgery, and wound care specialists is essential for optimizing recovery and minimizing complications like infection and delayed healing.

Hospital-specific pearls: • Early fasciotomy is key—don’t wait for imaging or lab results, act swiftly when diagnosis is clear. • Monitor pain and ICP measurements closely, especially in unconscious or non-communicative patients. • Coordinate early involvement of specialists like plastic surgery for wound management and rehabilitation for long-term recovery. • Avoid excessive sedation or regional anesthesia, as these may mask symptoms and delay diagnosis.

We close with system moves: a bundle that (1) triggers early fasciotomy pathways in high-risk patients, (2) automates ICP measurement orders when clinical exams are unreliable, (3) links to multidisciplinary care teams for postoperative management, and (4) sets up follow-up reminders to monitor recovery and prevent complications.

Compartment syndrome demands rapid diagnosis and intervention; proper pain management and complete decompression are essential for preventing irreversible injury—care that’s immediate on the wards and sustainable through rehabilitation.