The Six P’s of Compartment Syndrome

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.

1) Pain

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.

2) Paresthesia

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.

3) Pallor

Pale, shiny skin distal to the injury should raise our suspicion of compartment syndrome. Bruising may also be present.

4) Paralysis

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.

5) Pulselessness

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.

6) Poikilothermia

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.


  1. Jeffrey R. Vaughn says:

    I have treated lots of compartment syndrome cases over the years. I worked in an isolated mining community of about 12,000 people over 1,800 sq miles. The closest hospital was 50 miles away from the station I usually worked at. What we would generally see were workmen’s comp cases (usually crush injury) that had been treated and released from the local clinic with instructions to contact EMS if any of the S/S of compartment syndrome occurred. Treatment usually consisted of loosening of the splint (if there was one), elevation, and liberal analgesia and transport to the local hospital if the sole ortho surgeon was in town. If he was not in town or unavailable, the patient got a helicopter trip to our closest level one center (>175 ground miles away).

  2. Great summary and great points about pulses easiness being a late finding- I would say that pain and maybe parasthesia are the only early signs- the rest are late signs and that could be dead tissue. Good point also that it can happen even without trauma. In the active duty military population I treat I have seen a few cases with no trauma- not even strenuous activity- one case was after a game of basketball- no fracture or trauma with it.

    One thing the orthopods taught me- a really concerning sign is pain with active or passive stretch. So the patient has pain when you move ther fooorbit hour their assistance (passive) or when they move it on their own (active).

    Great review

    EM doc, EMT-B
    San Antonio TX

  3. Wow those were some awful typos on my part- damn autocorrect

    1st line- *pulselessness

    2nd to last line- *you move their foot WITHOUT their assistance (active)

  4. Robin Drake, RN says:

    Great article. I do what could be considered phone triage for a company, and we screen passengers and crew prior to air travel. From the perspective that crew worry A LOT about DVT, and Passengers often travel soon after fractures (think flying out of Denver in all but summer time) this is right on the mark for me to add to my considerations when there is a complaint of extremity pain. I will certainly share this with the other nurses!
    Steve: thanks for the clarification~

  5. Anonymous says:

    I had compartment syndrome without any explanation of why, all the doctors could tell me is that I needed a fasciotomy. I never recall ever hurting my legs on something or anything of that sort. The only symtoms I had was a severe burning sensation and the loss of range of motion in my foot. At first some doctors thought I may of had “drop foot” due to some neurological issue (I could not move my foot in the upward direction). That is until one recommended I speak to an orthopedist to rule out all muscle-skeletal possibilities. He connected the dots and realized that the increase of pressure (due to the compartment syndrome) may be effecting the nerves. I measured at a resting pressure rate of 36 and from my understanding above 30 indicates surgery is necessary. Not to mention mine is exercise induced. My point is I only had one of the “P’s” and that is pain. Are there any reasonable explanations out there?

  6. Shyla Smith, RN says:

    My 23 year old grand-daughter developed compartment syndrome out of the blue. She is not an athlete nor did she have a motor vehicle accident. Doctors in Pulllman, WA and Boise ID are stumped as to what caused it. She is keeping her leg elevated, drinking lots of water and waiting to start PT. Her last MRI showed that the situation was worse than when it first occurred on March 27 and the pressure has increased. The swelling refuses to decrease. Any suggestions? She is doing all that the Doctors ask her to do and they are doing everything all articles suggest they do. It is just a very scary situation for all of us.

  7. Im 22 years old serving in the military and have had just been diagnosed with compartment syndrome after three years of it, my veins stick out and i have lumps all over my legs which get worse when under taking physical activity im under a rehab clinic for it now but surgery has been mentioned a few times but the lack of interest in me no one has really told me anything except surgery is a last resort and it doesnt always work my main concern is the lumps as i have one on my left foot then all the way up my shin and one on my calf then on my right leg just two that are a few inches above my ankle. any extra advice on this would be greatful for my rehab

  8. Good work.

  9. dylanglorioso says:

    My best friend died 4 months ago from compartment syndrome. His kidneys failed. He was a bull rider and he got stepped on. The night before he died he went to the hospital becuz he was scared and he felt as id something was terribly wrong. They wouldnt do anything becuz he had no insurance. I’ve have yet to find any cases that someone has died from this. Is it that rare?

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  14. RE Shayla Smith.
    I am a 30 year old guy who has acute compartment syndrome and I was just released from the hospital after 5 long weeks. The Dr’s had to perform a faciotomy on my lower right leg within about 12 hours of the injury taking place. They had me hooked up to a vacuum for over a month until the swelling finally went down enough to be able to close the incisions. I’ve been home for about a week and the swelling in my foot and ankle feels like its getting worse rather than better. I have my foot elevated for 6 hours at a time and ice it constantly. I was just wondering how everything turned out and if you had any advice for me

  15. Lisa Johnson says:

    My 24 year old daughter, who is an athlete, has compartment syndrome. She has no medical insurance . She needs help from a doctor. She had no injury that she remembers. About 3-4 times a year, she experiences excrutiating pain. She ices her leg, continues to stand on her leg, a heating pad does not work for her. In fact, she experiences more pain with heat. She does not want to loose her leg. And does not want to stop playing rugby. Can someone help. Please contact me through email.

  16. Hi- I was injured at work in December, 2013. I was told that I had a minor knee sprain. I came back to the ER the next day because of significant swelling that ice, rest and elevation wouldn’t help. I was told that I needed to increase the circulation in my leg, so to do toe pumps all throughout the day, and the doc also ordered an MRI for 4 days later to make sure that all tendons were intact. A couple of hours after my MRI, I received a call from my pcp saying that I had an impacted femur and tibia fracture and torn lcl. Told to stop weight bearing and get to the ER so it could be immobulized. I followed directions, and saw a ortho on Friday (7 days after injury) and was told that there was so much damage done to my knee, surgery wasn’t possible. Long story short, I was really really misdiagnosed, from the beginning! I had a anterior compartment syndrome that was untreated, which resulted in foot drop, and now have developed CRPS. I have had multiple Paravertebral Nerve Sympathectomies in my L2 and am going to be doing a trial soon with a neurostimulator implant that hopefully will get me to where I can function daily, and not in pain. I currently have 7 doctors not including a Psychiatrist to help me with depression and dealing with living the rest of my life in pain…only being 34 years old. Has anyone else had a similar experience to mine?

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  21. I was attending a pain managment doctor an was given an anaglgesic a couple of times, the woman that checks me out and makes my appts. told me my insurance wouldnt pay for the next shot but would a steroid injection (I was getting them for lower back pain) the next day I had a tiny bit of numbness in my legs,so I thought it was possible inflamation,but the next morning it felt like I had a vice grip on my hips and my legs were going numb and felt as though they were on fire,I couldn’t even walk,I called the pain management place,rushed there and had to go in via wheelchair, P.A.. checked me out gave me a script for Lyrica and sent me on my way 3 hours later I was in such pain it felt like fireworks were going off in my legs. I went to the emergency room via ambulance and was screaming at the top of my lungs,the pain was unbearable,the doctor was laughing at me,he gave me a shot that did give me releif and sent me home,I was there 30 min.they called my husband to pick me up he even argued with the doctor that something was dire,so the next morning I went to my primary care doctor,at this time I was getting mentally unstable for some reason.My primary set up a doppler for a week from the time I was there, 2 days later I was hallucinating, my husband thought it was the Lyrica, the next day when I thought he was a robber he took me to a different emergency place,they took a doppler asap and that night was told if they didnt remove my leg I was going to die by the next morning, my bones were charred and part liquid,anyway please dont take this lightly,and are doctors taught this pressure test in medical school,if it wasnt for the doctor that removed my leg keeping himself from crying when he ha to resort to this,I would lose all faith in the medical community,my leg could have been saved when I went to the P.A. an she would have put me in the hospital. 3 doctors completely let me down.

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  27. I am a person with compartment syndrome. Motorcycle accident and motor crushed my left leg. The swelling was instant. Purple from thigh to calf. couldn’t afford surgeon so my doctor said it would go away in about 6 to 12 months. The pain and burning and tearing feeling never has went away in the year and two months yet. I cant stand or sit or sleep or even wear clothes on the area and to touch it is horrible. I have never had any pain meds because I don’t want to be on pain meds to survive. I wish there was a doctor who knew how serious this is. I have been to Six specialist and no one knows why is still hurts. It still purple and swollen on inner knee. now I’ve been out of work for over a year and no more insurance to continue to find a doctor who can help. I will just have to endure as much for as long as I can.

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  33. I had a crush injury and resultant compartment syndrome of ly leg from the knee thru my toes.. I tripped and fell and my 4 door pickup drove straight up my foot up to my knee.. My lower back was teetered on a box so my knee was driven to the garage floor by the truck.. It say there 30 min..EMT arrived and put the truck in park, it rolled down my leg and my foot inverted.. The truck sat on my ankle joint and tore all of the lateral ligaments from the bone and crushed my talus for another 20-30 min before the truck was air lifted off of me… The hospital did nothing and sent me home…
    2 months later I had to have my ankle repaired thanks in part to me ordering an MRI of my knee and ankle 2 days later (happened on a Saturday and ER refused to do an MRI)
    Long story short I still have terrible pain in my knee, lower leg and ankle especially at night…a deep terrible pain that keeps me up all night… Any ideas about why? How to help the pain other than tramadol and soma which doesn’t really work…
    Ischemia related? Pressures of my leg were never taken, they took the air cast off immediately at the ER and left my leg to swell after that with no meds, crutches, compression sleeve etc…
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    By the way the crush injury did show spontaneous osteonecrosis of my tibial plateau, medial upper tibia

  34. I was involved in an auto accident 2 1/2 years ago. I t-boned another car traveling at about 60mph. My car was totaled, and i was brought to the hospital on stretcher by an ambulance. I had two fractured ribs and both legs were extremely sore since my knees hit the dash. The next day my left and right lower legs were severely bruised and swollen. Purple, red, black and blue from my knee area to the inside of my foot. It was extremely painful. I made a number of trips to the doctors office and my left knee was x-rrayed a number of times. I was told the bone appeared to be swollen and they suggested that it may be bruised and that a hematoma was present in the area (it resulted in a huge pillow like lump). The left leg remained swollen for 6 + mos. Finally a doctor suggested I see an orthopedic surgeon. He prescribed physical therapy. Eventually (the therapist) treated the swollen area with Ultrasound. This area was very tender an painful. I continued to experience pain, itching, burning. My shins hurt at times, as did the back of my calf and the area just below my knee and to the right of the knee on my left leg. My leg and foot would fall asleep at times. I was referred to another Ortho surgeon who noticed a swollen area that resembled a thin like rope just below and to the right of my left knee. When touched it hurt like crazy.. he injected it with a pain killer and it relieved the pain immediately. He performed surgery and removed the nerve – he said it was fiberous, thick, knotted? Not what was expected. The pain came back after I recovered from the surgery. Not as intense but its there. it was especially bad when during a business trip, I had to run/jog to make a plane connection. It was pretty bad when I sat down but subsided shortly afterward – I continue to get numbness, pain down my lower leg front and back, (not in the knee joint but just below) – pain can extend toward the ankle. This has been with me since the accident 2 1/2 years ago. Could this be compartment syndrome? – sometimes I limp without realizing it, my foot at times feels heavy and dead. Since the surgeon removed the fiberous tissue/nerve it has not been “as bad” but it is still there.

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