Richard, a 14-year-old sports enthusiast and avid fisherman, left at daybreak with three friends to fish in the nearby lake. After setting up, they lay back on the hillside, anxious for the fish to start biting. Richard, while daydreaming of catching the largest bass ever found in the lake, dozed off. He was awakened by a sudden intense pain in his right foot. Looking down, he saw a snake slithering away. He felt his foot begin to swell, and upon examination he saw a puncture wound. Richard was taken to the ED where personnel asked for a description of the snake. It seemed that it was not poisonous. Medical treatment was provided, and prescriptions for narcotic pain medication and antibiotics were given. Richard returned home in the care of his parents with instructions to elevate his foot and apply ice intermittently for 24 hours.

That night, Richard experienced severe burning and unrelenting pain, unrelieved by the medication. The swelling had extended to his toes and his foot was hot to the touch. Richard returned to the ED where on examination he screamed in pain. The nurse suspected compartment syndrome.

An orthopedic surgeon found the intracompartmental (IC) pressure elevated in Richard’s foot. A diagnosis of ACS — acute compartment syndrome — was made. Richard was taken to the operating room (OR) for an emergency fasciotomy and debridement. He was started on intravenous antibiotics and underwent two additional debridement procedures to remove necrotic tissue. The wound was closed three days post injury. Richard was fortunate: He received a prompt and accurate diagnosis and immediate treatment, and sustained no permanent damage.

Compartment syndrome is a relatively uncommon, yet dangerous, orthopedic problem. Although this problem is somewhat rare, nurses should consider the possibility of its occurrence, especially in the two fairly typical locations it strikes. Closed tibial fractures are the most common precursors to compartment syndromes of the lower extremity, which occur in 3% to 17% of tibial fractures.¹ In one retrospective study done in Taipei from January, 1996 to June, 1997, the rate of compartment syndrome following tibial plateau fractures (fracture to either or both tibial condyles) was 10.3%. This study was done at a level I trauma center. A correlation was found between the type of fracture and severity of trauma with high-energy or blunt trauma increasing the risk of acute compartment syndrome.² In another retrospective study in New York from January, 1990 to January, 2002, acute compartment syndrome of the thigh was studied. Again, blunt trauma, such as that found in automobile accidents and contusions, increased the risk for compartment syndrome.³ A supracondylar fracture of the humerus is often the etiological factor in upper extremity compartment syndromes. This is the most common cause of compartment syndrome in children.

Eight-year-old Katherine presents to the ED after a fall during cheerleading practice. She is complaining of pain, warmth, and swelling in her elbow. An x-ray reveals a fracture of the humerus; after a cast is placed on her arm, she is sent home with a prescription for acetaminophen with codeine for pain. Over the next two days, Katherine’s pain remains intense and her mom brings her back to the ED. Suspecting compartment syndrome, the nurse calls an orthopedic surgeon immediately. Sure enough, Katherine is diagnosed with ACS, admitted, and taken to the OR for a fasciotomy.

Gone unrecognized, ACS can lead to ischemia, permanent injury to nerves and tissues, loss of function, and possible amputation of the involved extremity. In Richard’s and Katherine’s cases, the diagnoses were made early, and neither one suffered any permanent effects.

Who Gets It and Why?

Nurses may see patients with compartment syndrome in a variety of settings: clinics and physician offices, orthopedic units, sports medicine arenas, medical/surgical floors, EDs, schools, ORs, recovery rooms, and even labor and delivery units. Chronic compartment syndrome may occur in athletes, mimicking symptoms of shin splints, muscle strain, medial tibial stress syndrome, and stress fractures. Although compartment syndrome can be chronic, this article focuses on the acute condition.

Compartment syndrome is a condition in which tissue function and circulation is compromised in a closed compartment — the space within the muscle — due to rising pressure within that space. Pressure can arise from hemorrhage or edema associated with acute injury, or sustained external pressure on a limb from such things as constricting casts, dressings, and splints, and even prolonged positioning in long surgical procedures. Tibial fractures, open reduction and internal fixation of fractures, and surgical osteotomies are frequently cited as culprits.

ACS is not limited to musculoskeletal conditions bit it can also be a complication of burns, insect or animal bites, massive intravenous infiltration, and abdominal surgery.⁴ And two reported cases involved patients with newly acquired quadriplegic injuries, who were treated with elastic circumferential wraps while still in spinal shock; although the wraps were removed and reapplied at 12-hour intervals, both patients developed ACS.⁵ Other documented cases of compartment syndrome have been blamed on muscle hypertrophy and nephrotic syndrome.⁶

The ACS caused by a snakebite that was described in the case study at the beginning of this article is actually a rare occurrence. For example, a study of snakebites in 58 children in India only resulted in one case of compartment syndrome.⁷ When it occurs, it’s a complication more often associated with poisonous crotaline snakes such as rattlesnake, copperhead, and moccasin. The signs and symptoms of compartment syndrome are very similar to the toxic effects of snakebite,⁸ and if it’s unrecognized there is a high incidence of permanent tissue damage. Antivenom often used to treat snakebites plays a role in preventing complications such as ACS. Experts recommend that compartment pressures be monitored while the antivenom is administered for the purpose of detecting ACS early should it occur. Additionally fasciotomy, a procedure to relieve compartment pressures, is not advocated in most instances for the treatment for crotaline snakebites.

ACS has occurred in patients who developed the anesthetic complication of malignant hyperthermia; this was thought to be related to prolonged muscle contraction and release of fluids from the intracellular to the extracellular space, leading to the swelling of the muscle compartment.⁹ Cases have also been documented in the patients’ lower limbs following extended surgical procedures that use the lithotomy or Trendelenburg positions.¹⁰ Finally, cases have occurred in the abdominal compartment past surgical procedures. These cases have involved trauma patients involving burns or sepsis who required massive fluid resuscitation.¹¹

While the etiology typically involves trauma to the affected extremity, ACS may occur as a result of infection as well. Deep-tissue foot infections in patients with diabetes mellitus can develop into compartment syndrome. Of the 12 million Americans with diabetes, many have altered skin sensation in the lower extremities. Deep-tissue infections are a real problem in this population because as bacteria enter an opening in the skin, these patients are insensitive to the warning signs of infection. Similarly, the poor vascular status of the diabetic patient predisposes them to developing ACS.¹²

After the trauma, fluid leaks into the space within the muscle. This leakage raises intracompartmental pressure, which leads to tissue hypoxia. The result is a release of inflammatory mediators such as histamine which, in turn, heighten capillary permeability causing further fluid movement into the interstitial space. Progressive muscle edema and a rise in venous pressure ensue. The fascia that surrounds the muscle is inelastic and cannot expand to accommodate the fluid. Thus, the pressure within the compartment may rise to a point that tissue viability is threatened. This cascade of events can lead to tissue ischemia. Irreversible tissue damage may occur in as little as four hours following the onset of impaired perfusion.⁴

Patients suffering from compartment syndrome can have serious complications such as muscle weakness, paralysis, permanent muscle contractures, nerve damage, and ischemia severe enough to lead to amputation. Left untreated, compartment syndrome can cause an array of metabolic disturbances as well. A metabolic acidosis can result from the release of lactic acids from necrotic tissue. Potassium may be released from damaged tissue, which may result in hyperkalemia and potentially life-threatening cardiac dysrhythmias. Renal failure may result from obstruction of the renal tubules by excess myoglobin that is released from the necrotic muscle.

The Five “Ps” of Compartment Syndrome

The signs and symptoms of neurovascular compromise are often referred to as the five “Ps”: pain, pallor, paresthesia, paresis, and pulselessness.¹³ However, in ACS they are not clinically reliable because they are frequently late signs.¹³ Pain that is disproportionate to the original injury or precipitating factor is the earliest symptom of compartment syndrome and is caused by increasing pressure on the nerve endings.⁴ Richard, the snake-bite victim, was a classic example. The pain he described was deep, unrelenting, and unrelieved by narcotic medication, a sign of muscle ischemia. Pain from ACS is progressive and will intensify with passive stretching of the digits of the affected extremity — referred to as stretch pain. Paresthesia, such as numbness, or a burning sensation indicate increased edema and tissue pressure whereas pallor reflects decreased oxygen delivery to the tissues.⁴ Muscle weakness may occur and progress to paresis and paralysis of the affected extremity signaling tissue necrosis.⁴ Pulselessness is a late and ominous sign.^14,15

Using Diagnostics to Confirm Suspicions

Physicians typically use the measurement of intracompartmental pressure — which should be 0 mm Hg to 8 mm HG10 — as a benchmark for final diagnosis of compartment syndrome. Many practitioners measure pressure by relying on the Whitesides technique that uses equipment generally available in almost any medical setting — a mercury manometer (such as the bedside sphygmomanometer), intravenous tubing, a three-way stopcock, a 20 mL syringe filled with normal saline, and an 18 gauge sterile needle. The skin is cleansed with an antiseptic solution, and the needle is inserted into the muscle of the compartment. The pressure in the system is boosted by gently depressing the plunger of the syringe. A rise in tissue pressure can then be observed on the mercury manometer. While opinions differ on what value actually constitutes a diagnosis, many practitioners believe that when tissue pressure rises to 10 mmHg to 30 mmHg, there is not adequate perfusion to sustain tissue viability. In the presence of an elevated compartmental pressure reading and/or one or more of the symptoms being present, a diagnosis of compartment syndrome may be confirmed.⁶ At this point, time is of the essence. Immediate treatment can prevent tissue ischemia and loss of function. Once ACS is identified the affected extremity should be maintained at heart level, not elevated.^14,16 Elevation above heart level would increase the arterio-venous pressure gradient causing arterial blood flow to decrease, further compromising tissue perfusion. Some experts recommend intermittent or continuous measurements of compartmental pressures,¹⁶ to monitor the pressures in patients at risk for ACS and those who are being treated.

What Happens Now?

When ACS occurs in a casted extremity, uni-valving or bi-valving the cast can relieve pressure by 30% to 35% and prevent the need for fasciotomy.¹⁶ However, if compartmental pressures are greater than 30 mm Hg typically a surgical fasciotomy is performed, which involves incising the fibrous sheath covering the muscle allowing the swollen muscle to expand.⁶ Fasciotomy has also been recommended if the difference between diastolic blood pressure and compartment pressure (differential pressure) is 10 mmHg to 30 mmHg and the signs and symptoms of compartment syndrome are present.¹⁶ In addition, because children’s compartmental pressures are different than adults fasciotomy is advocated by some experts when  the difference between the child’s compartmental pressure and mean arterial pressure is less than 30 mm Hg.¹⁶

Fasciotomy is an emergency procedure that relieves the internal pressure caused by the expanding compartment. Depending on which compartment is affected, there may be up to four longitudinal incisions. The surgeon may also make a transverse incision to facilitate decompression of the space. Debridement of the ischemic tissue must also be done. The wound is then packed, left open, and covered with a dry sterile dressing.

Postoperative nursing care is vitally important. Monitoring the patient’s neurovascular status, changing dressings, and administering antibiotics and analgesics are the cornerstones of care. Patients need emotional support and education as well. They should understand that they may have to return to the OR for subsequent debridements and closure of the wound. And because skin closure often is not done immediately following fasciotomy, skin grafting is often needed at a later date. Although it may seem like a long road, reassure patients that when treatment is successful, the chances for a fully functional extremity are good.

Avoiding Litigation

Once diagnosed, compartment syndrome must be treated as a surgical emergency. Swift treatment is essential for the patient’s well being and can limit the risk of medical litigation. Compartment syndrome, if allowed to progress, may lead to permanent tissue damage and loss of the affected limb. A nurse may very well be named as a codefendant in such a case, especially when he or she fails to monitor the patient at risk and notify the physician of pertinent changes in condition.

A careful neurovascular assessment at appropriate intervals should be ongoing and timely. Those nurses who care for postoperative patients who have undergone nerve blocks must be particularly alert to neurovascular changes as the block may mask the painful symptoms of compartment syndrome. It is of utmost importance that any such changes be reported promptly and carefully documented.