Compartment Syndrome is a known complaint of orthopedic injuries, fractures, and crush injuries, and is an often overlooked side effect of tight splint or cast application. Compartment syndrome can also be the result of space occupying lesions, infections, or fasciitis.
Classically, compartment syndrome presents with severe pain, out of proportion to examination, pallor or pale coloration to the distal extremities, pulslessness due to compression of blood vessels limiting distal blood flow and, in its late stages, paresthesia, or complete loss of sensation due to nerve ischemia.
Muscles should be viewed as bundled fibers wrapped in fascia, and injury to those muscles can cause swelling, edema, and pain. When swelling exceeds the limit of the fascia wrapping the muscles, the swelling becomes very tight, and begins to compromise blood vessels.
Any splint, cast, or bandage should be removed and the extremity should be examined for pain and vascular flow. Palpable pulses, capillary refill, and sensation, if present are reassuring. Formal evaluation should be performed by measuring compartment pressures, which can easily be performed by using a compartment pressure device. Compartment measurement devices use hydrostatic pressure to measure the compartment of a muscle. Values greater than 30mmH20 are highly suggestive of compartment syndrome and warrant immediate orthopedic evaluation. Once calibrated, the device needle should be injected into the compartment of concern. Great care should be taken to insert the needle deeply into the compartment. See the diagram below for instructions to set up compartment pressure device.
Compartment pressures between 20-30 should be repeated to evaluate for worsening pressure levels. The definitive management for compartment syndrome is surgical fasciotomy, which can be performed emergently at the bedside, but ideally should be performed under sterile conditions in the operating room.
Fasciotomy will require extensive plastic repair, skin grafting, and is best managed in a setting that provides specialized services for long-term repair. See photo below for example of open fasciotomy: