Acute compartment syndrome after a tibial or forearm fracture declares itself first as pain out of proportion to the injury, and pain on passive stretch of the muscles in the compartment. Paraesthesia follows. A palpable distal pulse is normal until very late, because compartment pressure rarely exceeds arterial pressure. Waiting for pallor or pulselessness means waiting for irreversible muscle death.
- Suspect compartment syndrome when analgesic requirements keep rising after a fracture.
- Test pain on passive stretch of the toes or fingers at each review.
- Split the cast and dressings to skin at the first suspicion.
- Do not be reassured by a palpable pulse or capillary refill.
- Proceed to fasciotomy on clinical grounds; measure pressure only if the diagnosis is uncertain or the patient cannot report pain.
Why it matters
The classic 'five Ps' teach clinicians to wait for signs that arrive only after the muscle has died.
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