Tissue edema due to injury peaks at 24-48 hours, but vigilance should be maintained in the first week post-trauma, especially in cases requiring sequential surgical procedures, ongoing resuscitation, or in the presence of ischemia-reperfusion. The signs and symptoms of CS are the classic “5 P’s” which include: pain; palpably tense muscle compartments; paralysis; paresthesia’s or sensory deficit; and pulselessness.2 Pain out of proportion to the injury or with passive stretch of a muscle group is the most important clinical finding, but is often obscured in combat casualties due to altered mental status, heavy sedation, and mechanical ventilation. Palpably tense compartments are thought to be specific but not sensitive; this clinical finding is also highly subjective. Paralysis and paresthesias are less useful acutely as they can also result from direct neural trauma. Pulselessness is a late and ominous sign in civilian CS, but occurs more commonly in combat injuries, sometimes within minutes of an arterial injury or an expanding hematoma. The most common compartment syndrome is in the anterior leg.1-2 About 45% of all compartment syndromes are caused by tibia fracture. Open fractures, even with traumatic fasciotomy, have higher CS rates than closed fractures because they are more severe, with more swelling and more often injured arteries. The most commonly missed compartment syndromes are in the anterior and deep posterior compartments of the leg. The most commonly incompletely released compartments are also in the leg.1

Pressure measurement has significant limitations and is not recommended for routine use in theatre. Emerging technologies, such as ultrafiltration catheters, may eventually allow continuous pressure monitoring while providing pressure relief by suctioning interstitial fluid.15 When monitoring patients for the development of CS, serial clinical examinations are repeated hourly when risk is high and less frequently when low. Provider experience and training improves detection. Documentation is important for later providers and performance improvement.

In one study, burns sustained in combat have been associated with an increased fasciotomy rate.7 In the absence of crush injury, fracture, multiple trauma, over-resuscitation, electrical injury, or similar indications, prophylactic fasciotomy on burned extremities may increase morbidity and mortality and are not indicated. (For additional information on escharotomy and fasciotomy in the management of patients with extremity burns, see JTS Burn Care CPG).16