Case Study Review: Recognizing and Managing Acute Compartment Syndrome
Case Presentation
A 19-year-old collegiate running back sustains a high-impact collision during a Friday night game, resulting in a mid-shaft tibia fracture of the right lower leg. He is stabilized on the sideline, splinted, and transported to the local emergency department. By the time he returns to your attention the following morning, he is reporting severe, worsening pain that feels completely out of proportion to what you’d expect at this stage — and he’s describing a strange tingling sensation along the top of his foot. The compartment feels unusually tight and firm to palpation.
Your clinical instincts fire immediately: this could be acute compartment syndrome.
What Is Acute Compartment Syndrome?
The muscles of the extremities are organized into distinct compartments enclosed by tough, inelastic fascial membranes. Acute compartment syndrome (ACS) occurs when pressure builds within one of these closed compartments to a level that compromises circulation and tissue perfusion (Hammerberg, 2023). Without prompt intervention, the downstream consequences are severe — nerve dysfunction, muscle necrosis, rhabdomyolysis, acute renal failure, and irreversible outcomes including foot drop, permanent nerve damage, or paralysis (Klingensmith et al., 2008).
As an AT, you may be the first clinician to notice the warning signs — making your ability to recognize ACS early genuinely life- and limb-saving.
Common Causes in the Athletic Population
While ACS can result from a variety of mechanisms, the most relevant causes in sports medicine settings include:
- Long bone fractures (as in our case above)
- Crush injuries or severe contusions
- Soft tissue trauma with significant swelling
- Burn injuries
- Spontaneous hematoma formation
- Non-traumatic rhabdomyolysis or myositis
- Exertional compartment syndrome (a related but distinct chronic presentation)
- Restrictive dressings, wraps, or casts applied too tightly post-injury
Clinical Recognition: Know the Five P’s
Assessment for ACS traditionally centers on the Five P’s, though it’s critical to understand that not all five present at the same time — and waiting for all five is waiting too long.
1. Pain
Pain that is disproportionate to the injury is the hallmark early symptom. Pain with passive stretch of the muscles within the affected compartment is a particularly telling sign. If your athlete is requesting escalating pain medication and not getting relief, take note.
2. Paresthesias
Tingling, numbness, or abnormal sensation in the distribution of nerves running through the affected compartment is another early red flag — as in our case, where the athlete reported tingling across the dorsum of the foot.
3. Paralysis
Late sign — motor weakness or inability to move the affected muscles indicates significant neuromuscular compromise and represents a near-emergency window.
4. Pallor
Late sign — skin color changes suggesting compromised perfusion.
5. Pulselessness
Late sign — absence of a distal pulse indicates severe vascular compromise and potential irreversible tissue injury (Klingensmith et al., 2008).
Paralysis, pallor, and pulselessness are late-stage findings. Pain and paresthesias are your actionable early warning signs.
Additional physical findings to watch for include a tense or woody-feeling compartment on palpation, visible increase in limb girth, and systemic signs of rhabdomyolysis such as dark urine.
Making the Diagnosis
ACS is primarily a clinical diagnosis built on your history, mechanism of injury, and physical examination findings. In cases where the presentation is unclear, or in an athlete who is unable to communicate symptoms (e.g., unconscious or heavily sedated), compartment pressures can be objectively measured using a handheld manometer.
A compartment pressure reading within 30 mmHg of the athlete’s diastolic blood pressure, combined with an inconclusive physical exam, is the threshold that warrants surgical intervention (Klingensmith et al., 2008).
Management: This Is a Surgical Emergency
ACS is not a “watch and wait” situation. Once clinical suspicion is raised, the following steps must occur without delay:
1. Remove all external pressure immediately
Cut away or remove any casts, splints, compression wraps, or restrictive dressings from the affected extremity.
2. Activate the emergency referral pathway
Your athlete needs emergent surgical consultation, ideally within four hours of symptom onset to preserve limb function (Hammerberg, 2023).
3. Fasciotomy is the only definitive treatment
A four-compartment fasciotomy, a surgical incision through all four compartments of the lower leg, is the recognized gold standard treatment. This decompresses the compartments and restores perfusion before irreversible damage occurs (Modrall, 2023).
Back to Our Case
In our scenario, the AT’s early recognition of disproportionate pain and paresthesias — combined with a tense compartment on palpation — prompted an immediate call to the team physician and an urgent return to the emergency department. Compartment pressures were measured and confirmed to be elevated within the critical threshold. The athlete was taken to the operating room within three hours of presentation for a four-compartment fasciotomy, resulting in a full recovery with no permanent deficits.
The AT’s clinical suspicion made the difference.
References
- Hammerberg, M. (2023, March 9). Acute compartment syndrome of the extremities. UpToDate. https://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities
- Klingensmith, M., Chen, L. E., Glasgow, S., Goers, T., & Melby, S. (2008). The Washington Manual of Surgery (5th ed., p. 593). Lippincott Williams and Wilkins.
- Modrall, J. G. (2023, January 10). Lower extremity fasciotomy techniques. UpToDate. https://www.uptodate.com/contents/lower-extremity-fasciotomy-techniques
