Patients may present with evidence of advanced compartment syndrome of uncertain but likely prolonged duration, as in the case of a patient found obtunded or incapacitated. When evidence of irreversible muscle ischemia and necrosis (rhabdomyolysis) is observed, as indicated by the presence of myoglobinuria, renal failure, and dramatic elevations in creatine phosphokines (CPK), fasciotomy may increase the potential for further reperfusion injury. In addition, exposure of necrotic muscle by performing fasciotomy may necessitate extensive debridement and create large wounds with the potential for soft tissue infection. For these reasons, the panel recommends that fasciotomy not be performed in such circumstances. In such cases where there is an associated fracture, operative fracture care should be approached with caution and fixation methods that do not violate the compartment (external fixation, casting) should be considered.
POSSIBLE HARMS OF IMPLEMENTATION
When presented with the possibility of late ACS, clinicians should be wary of erroneously assuming the patient has an irreversible injury. In the absence of any reliable techniques to accurately determine the timing of the compartment syndrome, the clinician is left with few options. Fasciotomies in an extremity with irreversible compartment syndrome can lead to systemic reperfusion injuries and exposes devitalized muscle potentially increasing the risk of infection. A small incision to determine the presence or absence of devitalized muscle in the compartment may be a reasonable option. If necrotic muscle is found, extension of the incision is not advised. Fracture stabilization is warranted in these extremities in certain situations. In the short term, temporizing stabilization with external fixation or casting is preferred.
Future research to define serum biomarkers or determine imaging modalities that reliably establish the extent of muscle necrosis would be beneficial.