What is the optimum strategy for managing compartment syndrome in the context of crush injury?
Date First Published:
July 17, 2026
Last Updated:
July 17, 2026
Report by:
Dr Hannah Clancy, Senior Registrar, Emergency Medicine (Defence Medical Services, DMS Whittington, Lichfield)
Search checked by:
Leo Wood, Emergency Medicine Trainee
Three-Part Question:
In [patients with suspected crush injury] [conservative management vs early / late fasciotomy vs amputation] [improve morbidity and mortality]?
Clinical Scenario:
A 24 year old tree surgeon is brought into the emergency department after a tree she was felling landed on and trapped her arm. As she was working alone she was not found for several hours during which time the arm was trapped. You suspect she has sustained a crush injury to it. You consider what the best management strategy is with regard to the limb in improving her outcome.
Search Strategy:
Please see link below for comprehensive search strategy:
http://tiny.cc/CrushBestBETsLitSearch
http://tiny.cc/CrushBestBETsLitSearch
Search Details:
A search was conducted on 2nd and 6th December 2022 and updated on 19th November 2024 to include any relevant articles published in the intervening period. The following databases were searched:
- Medline on EBSCO platform
- CINAHL on EBSCO platform
- EMBASE on Ovid platform
Limiters:
- English language
- Last 10 years
- Conference abstracts excluded
- Medline on EBSCO platform
- CINAHL on EBSCO platform
- EMBASE on Ovid platform
Limiters:
- English language
- Last 10 years
- Conference abstracts excluded
Outcome:
40 articles screened. Identifying:
One systematic review comparing conservative management vs fasciotomy vs amputation in the management of crush injury.
Two retrospective observational studies.
One systematic review comparing conservative management vs fasciotomy vs amputation in the management of crush injury.
Two retrospective observational studies.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Surgical management of closed crush injury-induced compartment syndrome after earthquakes in resource-scarce settings. Gerdin M, Wladis A, von Schreeb J September 2012 Sweden | 14 review articles | Systematic review | Various primary outcomes depending on review but focussing on morbidity and mortality particularly with regard to limb function, complications of interventions and death. | Conservative management: | Based on narrative reviews, limited statistical analysis. Basic search strategy Only articles written in English are included. Much experience of crush injuries is from earthquake prone regions where English is not the native language. |
| 3 reviews favour conservative management over surgical, 1 considers conservative and surgical equally beneficial. | |||||
| Early fluid resuscitation, preferably prior to extrication, is recommended with the primary aim of limiting renal injury. | |||||
| Mannitol can be used to lower compartment pressures but should not be used in oliguric/anuric patients or those with acute renal failure. | |||||
| Limbs should be splinted to limit movement. | |||||
| Hyperbaric oxygen may play a role in limb salvage. | |||||
| Conservative treatment should be prioritised when patient presents 48-72hrs following onset of symptoms. | |||||
| Fasciotomy: | |||||
| Increased infection risk when closed compartment syndrome turned into an open wound. | |||||
| Complications of fasciotomy include sepsis and death. | |||||
| 9 reviews recommended fasciotomy after closed crush-induced compartment syndrome. | |||||
| 5 of these reviews recommended early over late fasciotomy (late being 6-12 hours post admission). Muscle and nerve damage is felt irreversible by late fasciotomy. | |||||
| One review suggested no role for fasciotomy due to the difference in pathophysiology from ischaemia induced compartment syndrome. | |||||
| Amputation: | |||||
| Discussed in 3 reviews to be used as a last resort as a life saving strategy to facilitate extrication. | |||||
| Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake Oda J et al. March 1997 Japan | 372 victims of the 1995 Hanshin-Awaji earthquake. | Retrospective observational study of hospitalised patients | Fasciotomy vs no fasciotomy | Fasciotomy performed: | Loss to follow up: 42 out of 372 patients attended long term follow up. Only 17 of these had fasciotomies. Time to rescue was a confounding variable and was an independent predictor of outcome. |
| Statistically significant differences in persistent muscle weakness between fasciotomy and non fasciotomy patients in the lower leg but not in the thigh: | |||||
| Anterior tibial (p = 0.0009), toe extensor (p < 0.0001), toe flexor (p = 0.0004), superficial peroneal (p = 0.003), deep peroneal (p = 0.03), tibial nerve (p = 0.01). | |||||
| Delayed rescue, fasciotomy and radical debridement may worsen physical prognosis and recovery. | |||||
| Fasciotomy not performed: | |||||
| Persistent muscle weakness is more commonly associated with sensory disturbance (p = 0.04). | |||||
| Fasciotomy in crush injury resulting from prolonged pressure in an earthquake in Turkey Duman H, Kulahci Y, Sengezer M May 2002 Turkey | 35 victims of the 2002 Turkey earthquake | Retrospective observational study | Fasciotomy performed | 16 patients had an urgent fasciotomy performed 8-21 hours post extrication. | Small patient numbers. Limited statistical analysis. Does not directly compare outcomes of different treatments. |
| Amputation | |||||
| Sepsis | Four patients required subsequent amputation due to sepsis. | ||||
| The most common complication was crush syndrome and the most severe was sepsis. | |||||
| The mean time to admission was higher in those who required amputation than those who didn’t. | |||||
| 8 patients who had fasciotomy regained normal function while four required further rehab or had ongoing functional / sensory loss. | |||||
| Fasciotomy wounds need careful monitoring and early antibiotics / debridement if signs of infection due to their propensity for infection. |
Author Commentary:
The quality of evidence to support of refute early fasciotomy/amputation is poor. That that is available does not suggest one method of treatment is clearly superior and is not of high enough quality to produce clinical guidelines. It would appear the benefit of different treatment types depends on time from the injury being sustained but this has been not objectively investigated.
Conservative management with the administration of mannitol was felt to be beneficial whenever the patient presented but must be used with caution in patients with or at risk of renal injury.
Fasciotomy is of greatest benefit when performed 0-6 hours post extraction, should be used with caution at 6-12 hours and not be used post 12 hours due to lack of benefit.
Amputation should be a last resort.
Conservative management with the administration of mannitol was felt to be beneficial whenever the patient presented but must be used with caution in patients with or at risk of renal injury.
Fasciotomy is of greatest benefit when performed 0-6 hours post extraction, should be used with caution at 6-12 hours and not be used post 12 hours due to lack of benefit.
Amputation should be a last resort.
Bottom Line:
Optimum surgical management of crush induced compartment syndrome is likely to be dependent on time from injury to treatment, resources and expertise available. Further research is required.
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Gerdin M, Wladis A, von Schreeb J. Surgical management of closed crush injury-induced compartment syndrome after earthquakes in resource-scarce settings.
- Oda J et al.. Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake
- Duman H, Kulahci Y, Sengezer M. Fasciotomy in crush injury resulting from prolonged pressure in an earthquake in Turkey