We sometimes overlook compartment syndrome while teaching isolated limb injury because it tends to develop hours to days after the initial insult. That late onset might suggest that it falls outside of the typical window of prehospital care. While I would agree that compartment syndrome is not a typical EMS finding, EMTs should be aware of what it is and recognize the signs as a potential limb threatening event.
There are a range of things that can create a compartment syndrome within a patients limbs and when a patient reports unusual pain and tenderness localized to a specific limb, it should be on our list of medical considerations.
Compartment syndrome occurs when injured tissue swells within the fascia and connective tissues inside of a limb causing an increase in the pressure within that “compartment”. Let’s break that down before we move on. Our muscles are split and divided by connective tissue similar to the way a freeway system might crisscross a busy city. These thin, fibrous layers of connective tissue, known as fascia, surround our muscles and bind together veins, arteries, nerves, ligaments and tendons together into functional groups.
When damage occurs to the muscle or muscle groups within the fascia, the resulting swelling and bleeding can create an increased pressure that, if left untreated, can choke off circulation, eventually leading to localized cellular hypoxia and death. The pressure within the closed fascia “compartment” becomes a tourniquet for the surrounding tissue within the compartment.
When left unrecognized or untreated, compartment syndrome can lead to loss of limb function and even loss of the limb itself.
We should consider compartment syndrome whenever a patient reports unnaturally extreme pain in a recently traumatized limb or a limb that has been immobilized post injury. Both fractures and crush injuries can create a compartment syndrome situation, but we should also consider it as a possibility if the patient experiences unusual pain and immobility after vigorous exercise. Other causes include any type of puncture or penetrating wound including surgeries and medical injections.
So what do we need to look for when we’re considering the possibility of compartment syndrome? First, our assessment needs to begin with a little history. If we were called for a traumatic injury, the underlying cause of the patient’s limb pain may be readily apparent, but for the patient with unusual, new onset limb pain we may need to dig a little deeper into what types of strain or trauma the limb might have recently experienced.
For our physical assessment, there are 6 P’s to consider. These six signs are often associated with compartment syndrome.
Pain is the universal symptom in compartment syndrome. While significant pain is almost always present as the pressure within the limb compartment rises, we may mistakenly attribute it solely to the injury itself. When pain seems dramatically out of proportion for the severity of the mechanism, consider the possibility of a compartment syndrome and look a little closer.
The pain typically felt with compartment syndrome is a dull, deep aching that is difficult to localize. Pain that increases upon manipulation of the muscle is also suspect for compartment syndrome.
This is that hallmark “pins-and-needles” sensation that we feel when one of our limbs has been without adequate circulation for a period of time. If you’ve ever had a crossed leg become temporarily numb while you were sitting down and then felt a rush of pin-prick sensations as circulation returned, you’ve felt two different types of paresthesia (numbness and tingling).
Numbness isn’t typically associated with our run-of-the-mill limb injuries. It can indicate nerve damage or it might suggest a progressing compartment syndrome.
Pale, shiny skin distal to the injury should raise our suspicion of compartment syndrome. Bruising may also be present.
More common in crush injuries, the total inability to move the limb distal to the injury might suggest compartment syndrome. If the limb is still intact, some movement should be possible in the distal extremity. If the limb is lifeless we should suspect significant muscle and nerve disruption and, possibly compartment syndrome.
We normally associate pulelessness with the severely angulated limb or massive soft tissue damage. But the absence of a pulse distal to the extremity can be caused by any mechanism that produces a tourniquet type effect.
A strong pulse certainly doesn’t rule out compartment syndrome. If the artery you are palpating doesn’t pass through the affected compartment, the pulse may be just fine. But finding a diminished or absent pulse in an otherwise intact limb should lead the caregiver to consider compartment syndrome. Also consider that delayed capillary refill may be a more subtle but earlier sign of decreased circulation in this patient.
Always a great buzz-word to drop at cocktail parties, the specific definition of poikilothermia is an organism or body part that normalizes its temperature with its surrounding temperature. If something attempts to achieve room temperature, it is poikilothermic.
In the context of compartment syndrome it refers to the finding of differing temperatures between the affected limb and the uninjured limb. Place a hand on the painful limb just distal to the injury or the site of pain. Then place your other hand on the opposite limb in the same location. If the affected limb feels cooler than the unaffected limb, this suggests that the injured limb is unable to thermoregulate.
Anticipate that you would only find differences in temperature with significant and advanced compartment syndrome.
When treating limb injuries, compartment syndrome is definitely a possibility that you should add to your differential diagnosis bag. Acute compartment syndrome is a limb threatening issue that requires surgical intervention. As prehospital providers, we should be aware of its hallmark clinical presentation. If we suspect compartment syndrome we should transport the patient to a facility with surgical capabilities and relay our findings to the hospital staff.
Now it’s your turn: Have you ever treated a patient with compartment syndrome? What was the mechanism of injury? How did you treat it? Leave us a comment and let us know.