Acute Compartment Syndrome

Acute compartment syndrome is a surgical emergency caused by raised pressure within a closed fascial compartment, leading to ischaemia. The 6 Ps are the clinical hallmark. Pain on passive stretch is the earliest and most sensitive sign. Delta…

BSCOS Compartment Syndrome Guideline

The pathway

1 · Recognise early — 6 Ps

Pain out of proportion to injury (earliest sign)
Pressure: compartment feels tense/woody
Pain on passive stretch of muscles in compartment (most sensitive early sign)
Pallor: reduced perfusion
Paraesthesia: nerve ischaemia
Paralysis: late sign — impending muscle death
Do not wait for late signs — clinical diagnosis

2 · Measure compartment pressure

Use Stryker intracompartmental pressure monitor or 18G needle manometer technique
Normal compartment pressure: <10 mmHg
Calculate delta pressure: diastolic BP − compartment pressure
Delta pressure <30 mmHg → emergency fasciotomy

3 · Emergency fasciotomy — do not delay

Do not delay for imaging, senior review, or confirmation if delta pressure <30 mmHg or strong clinical suspicion
Lower leg 4-compartment fasciotomy: anterior, lateral, superficial posterior, deep posterior compartments
Upper limb: volar and dorsal compartments of forearm
Thigh: medial and lateral if indicated

4 · Wound management post-fasciotomy

Fasciotomy wounds left open 48–72 hours
Negative pressure wound therapy (NPWT/VAC) may be applied
Return to theatre at 48–72h for wound inspection and delayed primary closure or split-skin graft

5 · Monitor for rhabdomyolysis

Serum CK — levels >5000 IU/L indicate significant muscle necrosis
Urine myoglobin — dark/cola-coloured urine
U&E and creatinine for AKI
Aggressive IV fluid resuscitation: target urine output >100 ml/hr in established rhabdomyolysis

6 · Post-fasciotomy care

Hourly neurovascular observations for 48h post-op
Elevate at heart level (not above — reduces perfusion pressure)
Daily wound review
Physiotherapy from day 1 post-closure
Renal referral if AKI develops

Drugs

Drug	Dose	Route	Notes
0.9% NaCl or Hartmann's	1–2L over 1–2h initially	IV	Aggressive IV hydration in rhabdomyolysis. Target urine output >100 ml/hr. Titrate to response.
Sodium bicarbonate 1.26%	500ml over 4–6h	IV	Alkalinise urine (target pH 6.5) to prevent myoglobin precipitation in tubules. Use in severe rhabdomyolysis. Senior decision.
Morphine	2.5–5mg IV titrated	IV	Severe pain control. Do not allow analgesia to mask evolving compartment syndrome signs — reassess regularly.
Mannitol 20%	0.5–1g/kg	IV	May promote osmotic diuresis in rhabdomyolysis. Senior decision. Monitor serum osmolarity (max 320 mOsm/kg).

When to escalate

Delta pressure <30 mmHg — immediate fasciotomy without any delay,Paralysis or complete anaesthesia developing — late ischaemic phase, emergency theatre,CK >5000 IU/L with rising creatinine — renal team involvement, consider renal replacement therapy,Urine output <0.5 ml/kg/hr despite aggressive hydration in rhabdomyolysis — nephrology referral,Persistent compartment syndrome signs post-fasciotomy — return to theatre for incomplete fasciotomy or missed compartment

Reference: BSCOS Acute Compartment Syndrome Guidelines / BOA Standards of Care

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