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Compartment syndrome results when interstitial tissue pressures within an osteofascial compartment is elevated to sustained, nonphysiologic pressures. This in turn decreases blood flow and can result in irreversible ischemia. 

Pathophysiology 

• In general, increasing pressure within a confined space will compromise the 
• circulation and function of its contents. 

• Progressive pathologic alteration in compartmental physiology is described as à  

• Increased compartment pressure 
• Venous outflow obstruction 
• Increased capillary permeability 
• Increased intracompartmental pressure 

• Decreased arterial perfusion 
• Decreased tissue oxygenation 
• Reversible ischemia 
• Irreversible ischemia. 

 

Pertinent Anatomy 

Starting with the Brachium/arm. There are 3 compartments of the arm à  

• Deltoid compartment which has (anterior, middle, and posterior subcompartments),  
• Anterior compartment. This contains the biceps, brachialis, and coracobrachialis –> MSK nerve. Median, ulnar, radial, lateral and medial antebrachial course distally in anterior compartment 

• Posterior compartment:  This contains the three heads of triceps, radial nerve, ulnar nerve, posterior antebrachial cutaneous 

• Separated from anterior compartment by the humerus and lateral and medial intermuscular septae 

• Next- Antebrachium/forearm: The forearm also contains 3 compartments: dorsal compartment, volar compartment, mobile wad 

• Volar and dorsal compartments separated by radius/ulna and interosseous membrane 
• Volar compartment: FDS, PT, PL. FCR, FCU (superficial); FDP, FPL, PQ (deep); When performing a compartment release it is important release subcompartments via epimysial layer.  

• In addition to this the Lacertus fibrosis (which originates from biceps tendon fanning distally/,medially to insert on PT fascia) should be released 
• This compartment contains median, ulnar, and anterior interosseous nerves 

• Dorsal: EDC, EDM, ECU (superficial); APL, EPL, EIP, supinator (deeper), supinator (separate) 

• This compartment contains the PIN 

• Mobile wad: brachioradialis, ECRB and ECRL- This compartment contains the radial nerve and SBRN 

 

• Hand: The hand contains the carpal tunnel/distal ulnar tunnel, thenar compartment, hypothenar compartment, dorsal and palmar interosseous compartments, digits. 

• Thenar compartment: FPB, AbPB, OP- recurrent branch of median nerve and contributions from ulnar (2 distinct fascial spaces) 
• Hypothenar compartment: ADM, FDMb, ODM- ulnar nerve (described as one compartment but can be 2 76% of time) 
• Adductor compartment: originates from long metacarpal to thumb metacarpal, dorsal to APL/thenar musculature  

• 4 dorsal/3 volar interossei (each distinct compartment) 
• Carpal tunnel 

 

The etiology of compartment syndrome is numerous and may include: 

• Fracture or soft-tissue injury (trauma) 

• Prolonged limb compression 
• Arterial injury 
• Reperfusion injury 
• Snakebite injury 
• Electrical burns 

• Hematologic disorders 
• Infections 
• Iatrogenic: 
• It is important to keep in mind that compartment syndrome can develop in the presence of an open wound. 

Diagnostic Considerations 

• History of injury- It is important to consider both intrinsic and extrinsic causes of compartment syndrome. Intrinsic causes may include intra-compartmental bleeding or swelling; extrinsic factors may include tight casts or dressings- both of which may increase intra-compartmental pressures. 
• Compartment syndrome is mainly a clinical diagnosis, although objective testing may be confirmatory, particularly in patients who are not able to give a reliable exam. 

• 2. Remember the “5Ps” of compartment syndrome- 

• Pain with passive stretch 
• Paresthesias 

• Paralysis 
• Pallor 
• Pulselessness 
• Pain with passive stretch 
• Increased pressure of the affected compartment on palpation may also be seen 

• When examining the patient, one should evaluate for swelling/dysvascular changes, palpation of swollen/tense compartments, and assessment for neurological dysfunction and pain out of proportion for injury. 
• A predictable progression of neurological dysfunction has been described and includes: 

• Subjective numbness followed by à 
• Hypesthesias to light touch/pinprick 
• Motor weakness 

• Anesthesia. 

• Objective testing/manometry 

Various methods of intracompartmental tissue pressure measurement have been proposed including: 

• Needle manometry 
• Indwelling wick catheter 

• Slit catheter 
• Stryker hand-held manometer. 

• Criteria for objective diagnosis of compartment syndrome includes… 

• b. Within 15-20 mm Hg of diastolic blood pressure 
• c. More than 30 mm Hg absolute pressure 

• Remember that normal tissue pressures are 0–12 mmHg. 
• Indications for objective testing/manometry include patients for whom a clinical examination is difficult or is not practical. This group includes patients who are: 

• Uncooperative or unreliable (the pediatric patient). 
• Unresponsive patients (obtunded or sedated patients). 
• Patients with neurological deficit(s) attributable to other conditions. 

Treatment 

• Recognition of compartment syndrome necessitates emergent surgical decompression of the involved compartment. Prophylactic fasciotomies may be indicated for patients with conditions presenting a high risk for the development of compartment syndrome. 

• Surgical management: Compartment syndrome is one of the few truly surgical emergencies of the upper extremity. Fasciotomies of the primary compartments are critical for decompression, and decompression of subcompartments and epimysiotomy has been demonstrated to improve tissue viability. 

 

There are several describe Incision Placement:  

• Forearm 
• Volar compartment: incision begins proximal to the elbow and includes a Henry or McConnel approach à the lacertus fibrosus is released à and volar decompression includes a carpal tunnel release à next the pronator quadratus and deep flexors  
• Dorsal compartment and mobile wad: A straight dorsal incisions is used, starting proximal to the extensor retinaculum and including the mobile wad 
• Hand 

• Carpal tunnel decompression is routine. 
• Two dorsal, longitudinal incisions are made; one between the index and long and the second between the long and ring finger metacarpals for accessing the interosseous muscles à remember that fibrous septae separate the dorsal and palmar interossei; adequate decompression of each is accomplished by meticulous circumferential dissection about the finger metacarpals. 
• The thenar muscles are released via a longitudinal incision along the radial aspect of the thumb. 
• Hypothenar muscles are released via an incision along the ulnar hand. 
• The adductor pollicis muscle may be released via an incision perpendicular to the skin crease of the thumb–index web space of the first web space. 

• Digits 
• Decision to release digital compartments is clinical and may be necessary after thermal injury. A midaxial incision on ulnar aspect of index, long, and ring fingers and midaxial incision on the radial aspect of thumb and little fingers may be used 

• Postoperative care. This should include efforts to minimize edema, functional orthosis to reduce stiffness and contractures, and a planned second look return to OR for repeat debridement at approximately 48 hours after initial surgical treatment.  
Postoperative therapy 
• Finally, we will discuss late or delayed diagnosis of compartment syndrome. This occurs after irreversible ischemia. Surgical debridement may not be indicated in subacute phase given risk of infection. 

• Tissue debridement may be considered for neurolysis or for delayed reconstruction with tendon transfers as appropriate. 

 

 

Questions: 

8yoF comes to the office with severe worsening pain and finger swelling/numbness 3 days after cast placement for fracture of left forearm. Pain continues after removal of cast. What is appropriate next step? (angio, CT, duplex US, EMG, manometry) 

• A: manometry 

 

37yF hx MVC with crush injury to arm, underwent bypass of brachial artery after humerus fixation. Postoperatively had increasing pain of forearm, with intact pulses. What is the appropriate diagnostic test? 
• A: manometry/measure compartment pressures 

 

• 19yM hx left leg pinned beneath a large granite stone for 2 hours. Leg is swollen, tense, erythematous, with palpable pulse and no fracture on XR. Increasing pain med requirement and pain on passive motion. What is most appropriate next step? 
A: fasciotomy