Region-Specific Compartment Syndrome

The leg has four clinically important compartments:

• Anterior: tibialis anterior, extensor hallucis longus, extensor digitorum longus, deep peroneal nerve and anterior tibial vessels.
• Lateral: peroneus longus and brevis with the superficial peroneal nerve.
• Superficial posterior: gastrocnemius, soleus and plantaris.
• Deep posterior: tibialis posterior, flexor hallucis longus, flexor digitorum longus, tibial nerve and posterior tibial vessels.

Anterior compartment syndrome may produce first web space paraesthesia and pain with passive plantarflexion of the ankle or toes. Posterior compartment involvement may produce pain with passive dorsiflexion and tibial nerve symptoms. The deep posterior compartment is a classic missed release.

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The forearm is usually considered as volar, dorsal and mobile-wad compartments. The volar side contains superficial and deep flexors; the median nerve, ulnar nerve and anterior interosseous nerve are clinically important. Pain with passive finger extension is the classic volar stretch sign.

Forearm compartment syndrome can follow distal radius fracture, both-bone forearm fracture, paediatric supracondylar fracture, vascular injury, transradial access complication, burns, tight casts, bleeding disorders or contrast extravasation.

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The hand is different because it is a small-compartment problem. The clinically relevant spaces include thenar, hypothenar, adductor, dorsal interosseous and palmar interosseous compartments. Carpal tunnel or Guyon canal decompression may be needed depending on nerve compression and the injury pattern.

Hand compartment syndrome is commonly caused by crush injury, injection injury, extravasation, infection, burns, prolonged compression and high-energy hand fractures. A swollen hand that is painful between the metacarpals is not just a soft-tissue injury until compartment syndrome has been considered.

Foot compartment anatomy is debated in the literature, with models ranging from several broad spaces to multiple individual compartments. For clinical practice, the important point is not the exact count; it is that the foot can develop compartment syndrome after crush, calcaneal fracture, Lisfranc injury, Chopart injury, high-energy midfoot trauma and vascular compromise.

Clinical signs are less reliable than in the leg. Severe foot pain, tense plantar swelling, pain with toe movement, sensory disturbance and high-risk mechanism should prompt pressure measurement when the diagnosis is uncertain.

The thigh has anterior, medial and posterior compartments. Thigh compartment syndrome is rare, but the size of the muscle mass means that delayed diagnosis can produce major rhabdomyolysis, renal injury, neurological deficit and death.

The gluteal region contains powerful muscle compartments and the sciatic nerve is at risk. Gluteal compartment syndrome is classically associated with prolonged immobilisation after loss of consciousness or substance use, but also occurs after trauma, vascular surgery, pelvic procedures and prolonged operative positioning.

Timing categories guide discussion and risk, but they do not remove the need for clinical judgement:

• Early suspected ACS: symptoms present, no established paralysis or necrosis.
• Established ACS: progressive pain, tense compartments, neurological change, concerning pressure trend.
• Delayed presentation: muscle viability uncertain, high risk of infection, rhabdomyolysis and poor function.
• Post-fasciotomy deterioration: recurrent pain, rising CK, persistent swelling or neurological decline may indicate incomplete release or ongoing necrosis.

1. Assess the patient and mechanism.
2. Remove splints, casts, circumferential dressings and constriction.
3. Keep the limb at heart level.
4. Give analgesia, but do not let pain relief hide serial deterioration.
5. Document regional examination: swelling, passive stretch, sensory, motor, pulses, Doppler.
6. Reduce dislocations and stabilise grossly unstable fractures when needed.
7. If clear ACS is present, proceed to urgent fasciotomy.
8. If uncertain, measure pressures and repeat the examination frequently.

Operate without delaying for pressure measurement when there is:

• high-risk injury with convincing escalating regional pain
• pain with passive stretch and tense compartment
• evolving paraesthesia or motor weakness
• vascular injury or repair with reperfusion swelling
• obtunded high-risk patient with concerning pressure findings
• failed improvement after removing external compression

Observation is only safe when:

• the mechanism is lower risk or the clinical picture is not convincing
• the examination is reliable and repeatable
• pressures are reassuring if measured
• there is a clear plan for timed reassessment
• staff know exactly what deterioration should trigger escalation

Observation is not a vague "wait and see" plan. It is active surveillance with documented repeat checks.

• Hand and foot: involve hand or foot and ankle expertise early when available.
• Thigh and gluteal: prepare for rhabdomyolysis, renal monitoring and possible repeated debridement.
• Vascular repair: coordinate with vascular surgery; unstable bone and reperfusion swelling both threaten the limb.
• Paediatric patient: anxiety, increasing analgesic requirement and agitation may be more useful than a classic adult verbal pain description.

Standard teaching is two-incision four-compartment fasciotomy:

• lateral incision releases anterior and lateral compartments
• medial incision releases superficial and deep posterior compartments
• identify and protect superficial peroneal nerve laterally
• avoid missing deep posterior fascia medially
• extend releases enough to decompress the full compartment length

Forearm fasciotomy usually begins with a generous volar release:

• release lacertus fibrosus proximally if needed
• decompress superficial and deep volar compartments
• include carpal tunnel release in most acute volar forearm releases
• inspect median nerve and vascular structures carefully
• add dorsal and mobile-wad release if there is dorsal swelling, raised pressure or uncertainty

Hand fasciotomy must target the small compartments:

• dorsal incisions can decompress interosseous compartments
• thenar and hypothenar releases are added when those compartments are involved
• adductor compartment may need specific release
• carpal tunnel or Guyon canal release depends on nerve compression and injury pattern
• early oedema control and hand therapy are essential to avoid stiffness

Foot fasciotomy is controversial because compartment anatomy and outcome evidence are less clear. The practical approach is:

• measure compartment pressures when the clinical picture is uncertain
• release clinically or pressure-positive compartments
• combine dorsal incisions with medial plantar or calcaneal-compartment access when indicated
• expect delayed wound problems and long-term clawing, stiffness or pain if diagnosis is late

For thigh compartment syndrome:

• release anterior, posterior and medial compartments when involved
• a lateral approach may access anterior and posterior compartments; medial release is added when required
• expect large-volume muscle swelling and bleeding

For gluteal compartment syndrome:

• release the gluteal compartments urgently when the diagnosis is clear
• assess sciatic nerve region and muscle viability
• plan repeated debridement if muscle is non-viable
• manage rhabdomyolysis and renal risk aggressively