Educational video describing clinical presentation of compartment syndrome.
my new book about compartment syndrome
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The 5 P's: late findings: traditionally the 5 P’s were used to diagnose compartment syndrome, however more recent studies have shown that these symptoms, except for pain are misleading. They reflect a late presentation and may not appear until compartment syndrome is fully established and irreversible damage has been done to the tissue. If diagnosis is withheld until all of the 5 P’s are present, the affected limb is often no longer viable.
Compartment syndrome needs to be diagnosed early in the impending stage. A high index of suspicion and measuring the compartment pressure is necessary for early diagnosis.
Clinical presentation
•Pain out of proportion to the primary injury or surgery is generally accepted as the first and most reliable sign of impending compartment syndrome. Escalating pain that is unrelieved by immobilization and that requires increasing analgesics should illicit high suspicion. Pain may be absent in late compartment syndrome due to tissue ischemia and necrosis or nerve injury.
•Swelling and palpable tenseness to the compartment occur as the intra-compartmental pressure rises and resigns of impending compartment syndrome. Casts or dressing will obscure these signs and should be split or removed if there is suspicion of compartment syndrome. Swelling and palpable tenseness are crude indicators and can be difficult to perceive, especially in the deeper compartments of the body. They are more reliable signs of compartment syndrome in more superficial compartments.
•Pain with passive stretch of the muscles of the affected compartment is an early sign and indicates impending compartment syndrome. When stretching the compartment, care should be taken to distinguish pain of the initial injury from more extensive pain. If the pain is perceived over the entire compartment rather than only at the site of injury, the diagnostic value of this sign increases. However, pain from the initial injury may also mask the pain of an impending compartment syndrome and lead to misdiagnosis.
•Paresthesia (or other sensory deficit) is a late sign indicating an established compartment syndrome. It is a result of nerve ischemia form elevated intra-compartmental pressure. Sensory abnormality will occur in the distribution of the nerve contained within the affected compartment. Knowledge of anatomical content involving each compartment is essential in connecting a sensory deficit in the nerve distribution area to a compartment where this nerve is contained. Paresthesia and other sensory deficits may occur within compartment syndrome if the initial injury caused nerve damage.
•Pulses: normal circulation- swelling and increased pressure-small vessels are occluded- pulse still can be felt. When impending compartment syndrome, smaller blood vessels become occluded and cannot maintain circulation. When intra-compartmental pressure exceeds diastolic blood pressure, arteriolar and capillary perfusion are blocked and the muscles within the compartment syndrome become ischemic. At the same time, however the systolic blood pressure may still force blood through the arteries of the compartment distally producing a pulse and capillary refill despite established compartment syndrome. Pulselessness is a very late sign indicating intra-compartmental pressure has risen enough to surpass systolic blood pressure and occlude a major artery. There is now total ischemia and fully established compartment syndrome. Tissue damage is likely severe and may necessitate amputation.
Clinical presentation in children
In children, pain that continues after a fracture reduction should arouse suspicion of compartment syndrome. As young children may not be able to relay their symptoms, restlessness, agitation, anxiety, and increasing analgesic requirements may indicate compartment syndrome. A child with head and extremity injuries need constant monitoring to diagnose compartment syndrome.
Misdiagnosis
There are multiple factors that can block the presence of clinical signs and symptoms in a patient with compartment syndrome and lead to a misdiagnosis.
•Altered mental status
•Children
•Regional anesthesia/local nerve block
•Post-injury or postoperative anesthesia
•Patient-controlled analgesia
•Associated nerve injury
•Narcotics/substance abuse
•Severe pain or numbness from polytrauma.
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