Compartment syndrome is a clinical diagnosis that must be based
primarily on the patient's clinical signs and symptoms. Pain out of
proportion to the injury, especially with passive stretch of the muscles in
the suspicious compartment or limb, is one of the most reliable indicators.
A palpably tense extremity compared with the uninjured limb is also an
important finding. The classic other P's of
pallor, pulselessness, and
paresis are not useful. Pallor and pulselessness
are rarely present in compartment syndrome and by the time paresis
manifests, the damage is largely irreversible.
In the unresponsive, obtunded, or anesthetized patient, measurement of
compartmental pressures with a needle and arterial line transducer or other
pressure-measuring device is useful (Figures 60–2 and 60–3). An absolute value above 30 mm Hg in the normotensive
patient is consistent with compartment syndrome. This value is diminished in
the hypotensive patient as the lower arterial pressure renders the limbs
even more susceptible to ischemic injury. Near infrared spectroscopy is
another noninvasive method suggested for monitoring the oxygen saturation of
hemoglobin and myoglobulin in the tissue at risk (Figure 60–4).
There are several compartments of the upper extremity that, when
injured, may result in compartment syndrome requiring fasciotomy in the arm,
forearm, or hand.
The arm has two compartments: anterior and posterior (Figure
Tissue compartments of the arm.
The forearm has three compartments: the volar and dorsal compartments and the
compartment containing the muscles of the mobile wad. Mubarak et
al.18 have demonstrated that these compartments are
interconnected, unlike the compartments of the leg (Figures 60–6 and 60–7). Consequently, decompression of the volar compartment
alone may decrease the pressure in the other two compartments. Regardless,
dorsal compartment fasciotomy should still be performed if it remains tight
after volar decompression.19 The muscles of the volar
compartment of the forearm include the digital and wrist flexors and the
forearm pronators. These muscles are tested by passive extension of the
digits and wrist and by supination of the forearm.
Tissue compartments of the forearm.
The dorsal forearm compartment contains the thumb and finger
metacarpophalangeal joint extensors, the ulnar wrist extensors, and the
forearm supinators and is tested by passive finger, thumb, and wrist flexion
and by forearm pronation. The mobile wad includes the brachioradialis and
the two radial wrist extensors and is tested by passive wrist flexion.
There are 10 compartments in the hand, the most prominent ones being the dorsal
and palmar interosseous compartments, of which there are four and three,
respectively (Figure 60–8). The other compartments are the
hypothenar, thenar, and adductor. The compartment containing the adductor
muscle of the thumb is often overlooked when doing fasciotomies. Studies
using renograffin dye had shown no connection between the dorsal interossei
and the other compartments, showing that each compartment has to be
Cross-section through the palm to show the
compartments of the hand.
The finger is enclosed in a tight investing fascia and is compartmentalized
by the fascia and the volar skin at the flexor crease. Although no muscle
bellies are distal from the metacarpophalangeal joints, ischemia and
engorgement can lead to tissue loss (Figure 60–9).
Cross-section through the finger.
The thigh muscles are divided into three compartments invested by thick
fascia: the anterior, medial, and posterior (Figures 60–10 and 60–11). Because thigh compartment syndrome is uncommon, it may go
unrecognized. A history of anticoagulant use is common in patients with
thigh compartment syndrome. Signs and symptoms include a history of thigh
swelling and/or hematoma and pain after a minor injury in a patient who is
anticoagulated.20,21 Although rare, the thigh syndrome can
also occur in patients after joint replacement surgery. The combination of
minor trauma and anticoagulation produces bleeding into muscle and tissue
spaces, leading to increased compartment pressure. Pain ranges from mild to
severe and may be elicited only when the hip and knee are flexed and
extended. Other findings of vascular
occlusion—loss of pulse, pallor,
paresthesias, and paralysis—are frequently absent.
Compartments of the upper thigh.
The lower leg contains four compartments, each invested by inelastic
fascia (Figures 60–12 and 60–13). Each
compartment contains a major nerve: the deep peroneal in the anterior compartment, the
superficial peroneal in the lateral compartment, the saphenous in the
superficial posterior compartment, and the tibial in the deep posterior
compartment. Swelling in the lateral or the anterior compartment can
compress both the deep and superficial peroneal nerves against the neck of
the fibula. The superficial peroneal nerve usually lies in the interval
between the two peroneal muscles for a short distance and then emerges
anterior to the peroneus brevis. It pierces the lateral compartment fascia
at the junction of the middle and distal third of the leg. The anatomy of
the superficial and deep posterior compartments is somewhat variable, but
both compartments, and especially the deep compartment, are frequently
involved in compartment syndrome.
Contents of the four compartments of the lower leg.
Lower leg compartments: Spatial distribution.
The foot has numerous rigidly bound compartments, and even mild
bleeding into these spaces can elevate the pressures dramatically
(Figure 60–14). According to Manoli and Weber,22
there are nine compartments in the foot. Three compartments run the entire
length of the foot (medial, lateral, and superficial). Five compartments are
contained within the forefoot (adductor and four interossei). The calcaneal
compartment is confined to the hind foot, but communicates with the
posterior compartment of the leg. This compartment contains the quadratus
muscle and the lateral plantar neurovascular bundle. The clinically most
relevant compartments are the medial, central, lateral, and
Coronal section of the foot through base of
metatarsals depicting the medial, central, lateral, and interosseous
A wide spectrum of injuries can result in compartment syndrome of the
foot; the most likely ones are crush injuries, especially those associated
with multiple metatarsal fractures. Often, the only reliable method of
diagnosis is by clinical suspicion and measurement of the intracompartmental
pressures. Loss of posterior tibial or dorsalis pedis pulse is notoriously
unreliable in the early diagnosis of the compartment syndrome. The earliest
clinical findings are muscle and nerve ischemia and pain. Although this pain
might be confused with that of pain from the injury itself, it may be
exacerbated by gentle, passive dorsiflexion of the toes, which stretches the
intrinsic muscles of the foot. Lack of sensation is generally accepted as an
important sign of nerve ischemia, but it is less reliable when compared with
a two-point discrimination and light touch over the plantar aspect of the
foot and toes.
Compartment pressure measurements are the only objective and accurate
tests to diagnose and record compartment syndrome.
Compartment pressure measurements are the only objective and accurate
tests to diagnose and record compartment syndrome, particularly because the
changes in the compartment pressures can precede the clinical signs of the
The central compartment can be measured by
passing the needle between the metatarsal and abductor hallucis muscle at
the base of the first metatarsal. The interossei
compartment is measured in two positions by introducing the
needle through the intermetatarsal spaces, preferably between the second and
forth web spaces to avoid punctures to the dorsalis pedis within the first
The calcaneal or quadratus
compartment is measured by inserting the needle 5 cm distal and
2 cm inferior to the medial malleolus and advancing through the abductor