Compartment Syndrome

Susan K. Emerson


  • Trauma.

    • Fractures (majority of cases).

    • Crush injuries.

    • Contusions.

    • Gunshot wounds.

  • Tight casts, dressings, or external wrappings.

  • Extravasation of intravenous (IV) fluids/medications or intraosseous infusion.

  • Burn injuries.

  • Post ischemic swelling (e.g., reestablished blood flow after blocked circulation).

  • Bleeding disorders.

Clinical Presentation

  • The five P’s (not always all together and not always reliable).

    • Pain with passive stretch.

    • Pain out of proportion to clinical situation.

    • Paresthesia.

    • Paralysis.

    • Pulses absent.

  • In children, the three A’s may precede the five P’s by several hours.

    • Anxiety (increasing).

    • Agitation.

    • Analgesic requirement.

Diagnostic Evaluation

  • Measurement of compartment pressure.

    • >30 mmHg typically requires fasciotomy.

      • Consider clinical picture in management plan.

  • Radiography of involved area to evaluate for fracture.


  • Medical emergency.

  • Institute therapeutic management while awaiting surgical specialty evaluation.

    • Remove binding devices (e.g., casts, splints).

    • Keep extremity at the level of the heart.

      • Elevation or dangling of extremity may further impair blood flow.

    • Control pain.

    • Administer oxygen.

    • Correct hypotension, if present.

  • Acute fasciotomy is the definitive therapy; open all involved compartments.

    • Typically performed at the bedside; may be performed in operating room (OR) depending on level of urgency.

    • Antimicrobials may be administered to prevent surgical infection.

      • Use coverage for common skin pathogens (e.g., Staphylococcus aureus).

  • Postprocedure: close evaluation for continued compartment syndrome and signs of infection, infection prevention, and pain control.

    • In many cases, the wound is closed after several days or a graft is placed.

Legg-Calvé-Perthes Disease

Dana L. Lerma


  • Not entirely clear.

  • Potential causes include infection, inflammation, trauma, and acetabular retroversion.


  • Most commonly affects children between 4 and 8 years of age.

  • More common in males.

Clinical Presentation

  • Mild to moderate pain in the hip on the affected side.

  • Pain may radiate to the thigh or knee, most commonly.

  • Occasionally, pain is more severe.

  • Leg length discrepancy or limp may be present.

  • Internal rotation and abduction of the affected leg are limited.

Diagnostic Evaluation

  • Radiograph of the hip or pelvis is the first diagnostic approach (Figure 19.1).

  • MRI or bone scan may also be indicated during the early stages of the disease progression to detect changes that may be more difficult to discern on radiograph.


  • Initial management is dependent on the extent of epiphyseal involvement.

    FIGURE 19.1 • Legg-Calvé-Perthes Disease Anteroposterior (AP) Radiograph of Bilateral Hips and Pelvis. AP radiograph of bilateral hips and pelvis of patient with Legg-Calvé-Perthes disease in the right hip.

  • Treatment is aimed at maintaining the femoral head properly placed in the acetabulum and maintaining adequate range of motion.

  • Mild Legg-Calvé-Perthes disease (LCPD).

    • Normal activity with observation.

  • Severe LCPD.

    • Activity restriction.

    • Physical therapy (PT).

    • Possible bracing to maintain proper positioning of the femur.

  • Long-term management of severe cases may include:

    • Extensive PT and rehabilitation.

    • Prolonged immobilization with use of orthotics or spica casting.

    • Close follow-up by an orthopedic specialist.

  • Rarely, surgery is indicated, but in some severe cases may be beneficial.


Susan K. Emerson


  • Acute or chronic.

Risk Factors

  • Hemoglobinopathies (e.g., sickle cell disease).

  • Chronic renal disease.

  • Type 1 diabetes.

  • Compromised immune system.


  • Staph. aureus is the most common organism in children (except neonates), 70% to 90% of infections.

    • Community-acquired methicillin-resistant Staph. aureus (MRSA) is becoming more prevalent.

  • Other offending organisms include group A hemolytic streptococcus, Streptococcus pyogenes, Strep. pneumoniae.

  • Group B streptococcus is the most common organism in neonates.

  • Pseudomonas is associated with puncture wounds, especially of the foot.

  • Haemophilus influenzae: incidence has decreased since advent of H. influenzae vaccine.

Clinical Presentation

  • Depends on child’s age and bone involved.

  • May have history of recent injury or infection.

  • Discrete tenderness at site of infection in affected bone.

  • May be associated with erythema, warmth, and edema of affected extremity.

  • Limp or refusal to bear weight; lower extremity.

  • Refusal to use extremity; upper extremity.

  • Fever, chills, vomiting.

  • Neonates may present with irritability, change in sleep habits, and decreased PO intake.

  • May appear toxic if long duration of infection.

Diagnostic Evaluation

  • Laboratory values.

    • White blood cell (WBC) count is highly variable with poor correlation to treatment.

    • C-reactive protein (CRP) is the most sensitive marker to monitor therapeutic response. Rises more quickly (e.g., within 6 hours of infection) and declines more quickly with effective therapy.

    • Erythrocyte sedimentation rate (ESR) rises and declines more slowly than CRP (e.g., elevated within 24-48 hours).

    • Blood cultures are positive in approximately 50% of cases and become negative soon after appropriate therapy is initiated.

  • Radiography.

    • Plain radiograph.

      • Early radiographs are often normal or demonstrate soft tissue edema.

      • Late radiographs (e.g., 1-2 weeks) demonstrate metaphyseal reaction and possibly an abscess (Figure 19.2).

    • MRI.

      • Highly sensitive and specific.

      • Demonstrates bone and soft tissue reaction.

      • Can assist in identifying associated abscess.

      • Differentiates between soft tissue and bone infection.

      • Imaging study of choice in patients with focal symptoms and strong suspicion of diagnosis.

    • Computed tomography (CT).

      • Identifies abscess and areas of destruction.

    • Ultrasound.

      • Maybe helpful in evaluating for abscess; though unable to image details of the bone.


  • Nonoperative.

    • Indicated in early disease or disease without abscess.

    • Antibiotics should be started intravenously once a biopsy/culture has been obtained.

      • IV antibiotics provide optimal bactericidal levels in the affected bone and reduce dissemination of disease.

        FIGURE 19.2 • Classic Osteomyelitis Anteroposterior (AP) Radiograph of Ankle. AP view of the ankle in a child with classic osteomyelitis. There are lytic areas in the fibular metaphysis with periosteal new bone formation. The epiphysis is normal.

      • Empiric antibiotics should include coverage for Staph. aureus (e.g., oxacillin or first-generation cephalosporins). If MRSA is suspected, select vancomycin, linezolid, or clindamycin.

    • May require peripherally inserted central catheter (PICC) line placement.

    • Transition to oral antibiotics once patient is afebrile and ESR and CRP have normalized; may require long-term IV antibiotics (e.g., 6-8 weeks).

    • Consider diagnostic imaging to evaluate for deep vein thrombosis (DVT) in patients with MRSA infection and in patients requiring a long hospital stay, admission to the intensive care unit, or surgical intervention.

    • Consultation with orthopedic surgeon, infectious disease specialist, and occupational/physical therapist.

  • Operative treatment.

    • Indications.

      • Abscess on radiographic study.

      • Failure to respond to antibiotics.

      • Purulent drainage on aspiration.

      • Chronic infection.

    • Removal of abscess/purulent drainage.

    • IV antibiotics: may require PICC line placement for long-term IV antibiotics.

    • Transition to oral antibiotic when patient is afebrile and ESR and CRP have normalized.

    • Consider diagnostic imaging to evaluate for DVT.

    • Consultation with orthopedic surgeon, infectious disease specialist, and occupational/physical therapist.

Jan 30, 2021 | Posted by in NURSING | Comments Off on Musculoskeletal

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