Acute compartment syndrome

Last updated: February 1, 2023

Summarytoggle arrow icon

Acute compartment syndrome (ACS) is caused by tissue ischemia due to increased pressure within a fascial compartment. It is a surgical emergency that is characterized by rapidly progressive pain and swelling in an extremity and is often precipitated by traumatic injury. Signs of poor tissue perfusion (e.g., pallor, pulselessness) and nerve damage (e.g., paresthesia, paralysis) occur in later stages of ACS and are suggestive of irreversible tissue damage. Diagnosis of ACS is based on clinical findings and confirmed by measurement of intracompartmental pressures. ACS requires fasciotomy within 4–6 hours to prevent irreversible tissue necrosis.

Other types of compartment syndrome include chronic exertional compartment syndrome, which is characterized by recurrent extremity pain during exercise or exertion, and abdominal compartment syndrome, which is caused by increased pressure within the abdominal cavity. See “Chronic compartment syndrome” and “Abdominal compartment syndrome” for details.

Etiologytoggle arrow icon

Etiology and risk factors for acute compartment syndrome

Causes of external compression

Causes of internal compression

Trauma-related causes
  • Burn eschars
  • Constrictive bandage/cast applied before the limb has stopped swelling

Non-trauma-related causes

  • Prolonged poor positioning of limbs (e.g., of immobile patients)
  • Increased capillary permeability (e.g., due to shock)
  • Spontaneous bleeding in coagulopathic patients

Because shock leads to reduced peripheral circulation, patients with polytrauma are at a high risk of compartment syndrome with muscle ischemia.

Pathophysiologytoggle arrow icon

External or internal forces as initiating event → increased compartment pressure obstruction of venous outflow and collapse of arterioles→ decreased tissue perfusion lower oxygen supply to muscles → irreversible tissue damage (necrosis) to muscles and nerves after 4–6 hours of ischemia

Clinical featurestoggle arrow icon

Signs and symptoms of ACS typically progress rapidly over a few hours but the presentation and onset are highly variable. [1][2][3]

  • Early features
    • Pain out of proportion to the extent of apparent injury
      • Worsens with passive stretching or extension of muscles
      • Extreme tenderness to touch
    • Soft tissue swelling
    • Tight, wood-like muscles
  • Later features
    • Neurologic deficits
      • Paresthesia (e.g., pins and needles sensation)
      • Sensory deficits
      • Muscle weakness or paralysis
    • Impaired perfusion
      • Cold extremity with pallor or cyanosis (uncommon)
      • Absent or weak distal pulses

Clinical features of compartment syndrome may be difficult to detect, especially in patients who are unable to report sensory symptoms (e.g., patients with altered mental status, comorbid trauma, or regional anesthesia). [3]

Arterial pulses remain detectable in all but the most severe cases of ACS and should not be used to exclude the diagnosis. [4]

The 6 Ps of acute limb ischemia (Pain, Pallor, Paresthesias, Poikilothermia, Pulselessness, and Paralysis) are seldom all present in early ACS.

Subtypes and variantstoggle arrow icon

Acute compartment syndrome may occur in any enclosed fascial compartment. It most commonly occurs in the lower legs and arms but the feet, hand, thighs, and gluteal region may also be affected. For acute abdominal hypertension and compartment syndrome, see “Abdominal compartment syndrome.”

Anterior compartment syndrome of the lower leg

Forearm compartment syndrome [3][5][6]


Diagnosticstoggle arrow icon

Approach [1][3][10]

Diagnosis is based on clinical findings but is typically confirmed with early measurement of compartment pressures.

In patients with obvious clinical features of compartment syndrome, consider forgoing diagnostics and proceeding immediately to urgent fasciotomy. [2]

Invasive compartment pressure measurement [1][3][10]

  • Indication: suspected ACS with equivocal clinical findings
  • Contraindications: no absolute contraindications [2]
  • Technique [2]
    • Equipment: Multiple systems with similar accuracy are available; follow local protocols. [11]
    • Measure pressure in the compartment of concern and all adjacent compartments. [12][13]
    • Serial measurements are recommended if pressures are normal but clinical concern for ACS persists.
  • Findings: The following support a diagnosis of ACS. [1][3][10]
    • Intracompartmental pressure ≥ 30 mm Hg
    • Delta pressure ≤ 30 mm Hg (ΔP = diastolic blood pressure - intracompartmental pressure)
    • Rising or sustained elevation of compartment pressure
  • Complications: infection, bleeding, tissue injury [2]

Critical pressure thresholds for performing fasciotomy are not absolute; always consider clinical findings when making management decisions.

Additional studies [1][3][10]

Laboratory and imaging studies are not used for diagnostic confirmation but may help identify the underlying cause of ACS or associated complications. [2]

Do not rely on noninvasive perfusion assessment (e.g., pulse oximetry, arterial Doppler) to assess for ACS because arterial blood flow may be detectable even in advanced compartment syndrome. [1]

Differential diagnosestoggle arrow icon

Differential diagnoses of compartment syndrome
Features Acute compartment syndrome Deep vein thrombosis Acute limb ischemia Rhabdomyolysis
  • Traumatic or non-traumatic
Clinical features
  • Often asymptomatic
  • Nonspecific pain and calf swelling
  • Myalgia
  • Generalized weakness
  • Darkened urine (red to brown)
  • Delta pressure ≤ 30 mm Hg
  • Surgical and supportive treatment
  • IV fluid administration


The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Immediate management [3][10]

ACS is a surgical emergency and requires emergent fasciotomy, as irreversible tissue necrosis and functional impairment can occur within 4–6 hours of onset.

Supportive care [3][10]

Avoid elevated positioning of the limb, as this may worsen ischemia by reducing blood flow.

Surgical treatment [3][4][10]

Acute management checklisttoggle arrow icon

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Prognosistoggle arrow icon

The prognosis depends on the amount of time that has elapsed prior to performing the fasciotomy: [4]

  • ≤ 4–6 h: almost complete recovery
  • 6–12 h: first necroses
  • ≥ 12 h: necroses; little or no return of function

Referencestoggle arrow icon

  1. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment Syndrome of the Forearm: A Systematic Review. J Hand Surg. 2011; 36 (3): p.535-543.doi: 10.1016/j.jhsa.2010.12.007 . | Open in Read by QxMD
  2. Duckworth AD, Mitchell SE, Molyneux SG, White TO, Court-Brown CM, McQueen MM. Acute Compartment Syndrome of the Forearm. J Bone Joint Surg. 2012; 94 (10): p.e63.doi: 10.2106/jbjs.k.00837 . | Open in Read by QxMD
  3. Long B, Koyfman A, Gottlieb M. Evaluation and Management of Acute Compartment Syndrome in the Emergency Department. J Emerg Med. 2019; 56 (4): p.386-397.doi: 10.1016/j.jemermed.2018.12.021 . | Open in Read by QxMD
  4. Taylor RM, Sullivan MP, Mehta S. Acute compartment syndrome: obtaining diagnosis, providing treatment, and minimizing medicolegal risk. Cur Rev Musculoskelet Med. 2012; 5 (3): p.206-213.doi: 10.1007/s12178-012-9126-y . | Open in Read by QxMD
  5. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  6. M. Stavrakakis I, E. Magarakis G, H. Tosounidis T. Hand Compartment Syndrome. IntechOpen ; 2021
  7. Lutter C, Schöffl V, Hotfiel T, Simon M, Maffulli N. Compartment Syndrome of the Foot: An Evidence-Based Review. J Foot Ankle Surg. 2019; 58 (4): p.632-640.doi: 10.1053/j.jfas.2018.12.026 . | Open in Read by QxMD
  8. Adib F, Posner AD, O’Hara NN, O’Toole RV. Gluteal compartment syndrome: A systematic review and meta-analysis. Injury. 2022; 53 (3): p.1209-1217.doi: 10.1016/j.injury.2021.09.019 . | Open in Read by QxMD
  9. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  10. American Academy of Orthopaedic Surgeons/Major Extremity Trauma and Rehabilitation Consortium Management of Acute Compartment Syndrome Clinical Practice Guideline. Updated: December 7, 2018. Accessed: October 11, 2022.
  11. Boody AR. Accuracy in the Measurement of Compartment Pressures: A Comparison of Three Commonly Used Devices. J Bone Joint Surg. 2005; 87 (11): p.2415.doi: 10.2106/jbjs.d.02826 . | Open in Read by QxMD
  12. Cone J, Inaba K. Lower extremity compartment syndrome. Trauma Surg Acute Care Open. 2017; 2 (1): p.e000094.doi: 10.1136/tsaco-2017-000094 . | Open in Read by QxMD
  13. Raza H, Mahapatra A. Acute Compartment Syndrome in Orthopedics: Causes, Diagnosis, and Management. Adv Orthop. 2015; 2015: p.1-8.doi: 10.1155/2015/543412 . | Open in Read by QxMD
  14. Elliott KGB, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003; 85-B (5): p.625-632.doi: 10.1302/0301-620x.85b5.14352 . | Open in Read by QxMD
  15. Glass GE, Staruch RMT, Simmons J, et al. Managing missed lower extremity compartment syndrome in the physiologically stable patient. J Trauma Acute Care Surg. 2016; 81 (2): p.380-387.doi: 10.1097/ta.0000000000001107 . | Open in Read by QxMD

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