You may know the 5 P’s, but it is easy to be fooled. The 5 P’s cannot be used if the patient is obtunded. Pallor, pulselessness, and paralysis are all late findings, and motor weakness can be limited due to pain. It is important to add a definitive pressure measurement to assure a definitive diagnosis of compartment syndrome. Proven in many clinical studies, the diagnosis of compartment syndrome can be easily missed or delayed, and the cost of a delayed or missed diagnosis to the patient and to the hospital can be extreme. By performing the measurement of the intra-compartmental pressure of the patient, the physician adds a definitive measurement to their clinical assessment.
While acute compartment syndrome is most often suspected with an extremity fracture, Mavor in 1956 first described chronic compartment syndrome due to exertion in young athletes. The diagnosis of compartment syndrome is commonly missed or delayed. Physicians often refer to the 5 P’s (pain, pallor, paresthesia, pulselessness, and paralysis), but it is easy to be fooled. The 5 P’s are most effective in accordance with a definitive pressure measurement. By measuring the compartment pressure of the patient, the physician receives a definitive pressure measurement that results in a data-driven decision.
Brief Case Description
In this case, a 28-year-old runner presented to the emergency department expressing months of worsening bilateral lower extremity pain. The patient noted, “The pain is always in my lower shins, and after I stop, the pain goes away after 15 minutes. I just thought that it was shin splits, which I have had in the past, but this time the pain just isn’t going away.” The physician measured the patient’s compartment pressures immediately and the patient obtained pressures of 40mmHg in both anterior compartments. The patient was immediately taken to the OR for a fasciotomy.
The patient had several red flags that needed to be considered prior to his diagnosis. First, he is an avid runner and feels continuous pain in his lower legs, even at rest. The patient had completed his workout seven hours before getting to the hospital and his pain had not abated. The patient also had significant palpation with weakness of the involved compartments. This clinical history of the patient should also be noted within the diagnosis.
There are hundreds of case reports and clinical studies including athletes and runners with advanced training regimens who are diagnosed with compartment syndrome. It is important to be aware and mindful of the symptoms and effects of compartment syndrome. The condition is due to continual overuse and usually affects young endurance athletes (soccer, lacrosse, football, etc.). Men and woman can be equally affected.
Intervention and Outcome Summary
Exertional Compartment Syndrome can occur in any athlete, particularly runners, or anyone who experiences overexertion. The diagnosis is often delayed or missed entirely due to the lack of education around compartment syndrome and the immediate pain attribution to other conditions. Often pain in the lower legs gets immediately compared to as “shin splints.” If you are feeling continuous pain in the lower legs, even while at rest, it is important to consult a healthcare professional immediately. The results of a missed or delayed diagnosis can be severe.
Emergency Physicians Monthly
Brit Long, MD and Alex Koyfman, MD