Key Points
- Confirm diagnosis early with highest‑yield tests (and do not let testing delay time‑critical therapy).
- Use explicit hemodynamic, respiratory, and neurologic targets to guide escalation.
- Document disposition criteria, follow‑up, and patient education before discharge.
Algorithm
- Primary survey and neurovascular check (5 P’s; pulses may be present).
- Remove casts/dressings; keep limb at heart level (not elevated).
- Assess pain with passive stretch and escalating analgesic requirement.
- If exam unreliable → measure compartment pressures in all compartments.
- ΔP ≤30 mmHg or progressive neuro deficit → notify ortho emergently.
- Resuscitate, correct coagulopathy, and consent for fasciotomy.
- Urgent 4‑compartment fasciotomy (e.g., leg: anterior/lateral & superficial/deep posterior).
- Intra‑op debridement of non‑viable tissue; leave wounds open with vessel loop/NPWT.
- ICU/step‑down monitoring: CK, electrolytes, urine output (target ≥0.5–1 mL/kg/h).
- Second‑look debridement at 24–48 h; plan staged closure/skin grafting.
- Address precipitant (reperfusion, fracture fixation, anticoagulation issues).
- Rehab planning and complication surveillance (infection, contracture, neuropathy).
Clinical Synopsis & Reasoning
Emergent limb‑threatening condition recognized by severe pain out of proportion, pain with passive stretch, tense compartments, paresthesias, and evolving motor deficits. When exam is equivocal, measure pressures; a delta‑pressure (diastolic minus intracompartment) ≤30 mmHg supports diagnosis. Remove constrictive dressings, keep limb at heart level, and perform prompt fasciotomy—ideally within 6 hours of ischemia.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or procedural interventions when predefined failure criteria are met. Define ICU, step‑down, and ward disposition triggers explicitly, and arrange specialty consultation early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitating factors
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC | Anemia/leukocytosis | Context‑specific | Trend response |
| BMP | Electrolytes/renal | Derangements common | Renal dosing/monitoring |
| Condition‑specific imaging | Per topic | Diagnostic hallmark | Do not delay with red flags |
| Compartment pressure | Diagnostic confirmation when exam unclear | ΔP ≤30 mmHg | Serial checks in obtunded patients |
| Creatine kinase/urinalysis | Rhabdomyolysis detection | CK↑, myoglobinuria | Manage hyperkalemia/AKI risk |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Analgesia (multimodal) | Opioid/non‑opioid | Immediate | Pain control pre‑op | Avoid masking progression |
| Crystalloid resuscitation | Volume expansion | Immediate | Optimize perfusion | Avoid overload |
| Tetanus prophylaxis | Immunization | Hours | Wound management | Per immunization status |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy
Patient Education / Counseling
- Explain red flags, adherence, and the follow‑up plan; provide written instructions.
References
- See bibliography — Link