Compartment syndrome

Neurovascular Assessment
Essential for the early recognition of neurovascular deterioration or compromise. Delays in recognizing
neurovascular compromise can lead to permanent deficits, loss of a limb and even death. Neurovascular
deterioration can occur late after trauma, surgery or cast application.
Components of the Neurovascular Assessment (Schreiber, 2016)
The neurovascular assessment of the extremities is performed to evaluate sensory and motor function
(“neuro”) and peripheral circulation (“vascular”). The components of the neurovascular assessment
include pulses, capillary refill, skin color, temperature, sensation, and motor function. Pain and edema are
also assessed during this examination.
Comparison of assessment findings bilaterally is extremely important. Even subtle changes can have
significant implications. Remember to include neurovascular assessment findings of all extremities in
your documentation and to notify the appropriate health care provider of any changes.

Pulses
Pulses are palpated to sense the movement or flow of blood through the peripheral vessels.
Assessment:
• Palpate pulse points with the pads of your middle and index fingers, applying gentle pressure.
• Mark any palpable pulse points with a pen to facilitate ongoing assessment.
• Specify which pulses are palpable, i.e. dorsalis pedis and posterior tibialis for lower limbs and radial
pulse for upper limbs (refer to the pictures below and as indicated on the form).
• Assess the pulse (grade it as strong, weak or absent).
• Record the pulse distal to injury and/or surgical site. Note if a Doppler was used to assess the pulse.
• If the patient has a plaster or bandage in situ, record ‘unable to test’.
Compartment syndrome

Capillary refill
• Assess capillary refill by pressing on the nailbeds to evaluate the peripheral vascular perfusion.
• Note how long it takes for the distal capillary bed to regain its color after pressure has been
applied to cause blanching (Pickard, Karlen, & Ansermino, 2011).
• Capillary refill time of two seconds or less is normal for an adult; prolonged capillary refill time
can indicate abnormal perfusion.
• Capillary refill time can be affected by age, temperature, ambient light, and pressure application
(Pickard, Karlen, & Ansermino, 2011).

Skin color
• Compare the color of the skin bilaterally.
• Consider the patient’s usual skin tone and any skin conditions when performing this assessment;
cyanosis can present differently in different skin tones.
• Pallor or cyanosis may indicate inadequate arterial supply; dusky, cyanotic, mottled, or purple black
coloration may indicate inadequate venous return.
• Shiny and pale skin, suggesting pressure in the affected area, may be a sign of compartment syndrome,
which requires immediate intervention to prevent vascular compromise that can result in muscle and
nerve ischemia (Schreiber, 2016).
Temperature
• Use the back of your hands to assess skin temperature bilaterally.
• Skin should be warm to touch. Cool skin may indicate inadequate arterial supply; warmth may indicate
inadequate venous return or infection (Schreiber, 2016).

Sensation
Compartment syndrome

Changes in sensation, such as numbness or tingling in the extremity can indicate neurovascular
compromise.
Assessment:
• Ask the patient to close his/her eyes prior to initiating assessment of sensory function.
• Test each nerve-related area using the tip of your index finger.
• When testing sensation, the location of numbness, tingling or prickling must be determined to indicate
distribution of vascular compromise or nerve damage.
• Assess and record the nerve sensation as normal, pins and needles or absent.
• Avoid using sharp objects unless indicated.

Motor function
Motor function assesses:
• normal movement of the muscles in the course of a nerve’s innervation
• strength of movement against resistance
• the presence of pain associated with passive movement.
Assessment:
Compartment syndrome

• Test the active unassisted movement initially. If a patient’s active movement is impaired or absent, passive
movement must be tested. Investigate and document the reason for impaired or absent active movement, e.g.
nerve block, limited by pain.

• Notify the medical officer of the appropriate specialty if there has been a decrease in motor function
since the previous assessment.

• Assess and record movement as full, impaired or absent in comparison to the unaffected limb as active and/or
passive.

Upper limb movement assessment

To assess for normal upper limb movement the following nerves are tested.

Radial nerve Median nerve Ulnar nerve

Test the radial nerve through thumb Test the median nerve through Test the ulnar nerve through finger
abduction. thumb opposition/ ability to bring the abduction.
thumb and little together so they are
touching.

Lower limb movement assessment

To assess for normal lower limb movement the following nerves are to be tested.

If ankle dorsiflexion or plantar flexion is restricted by plaster then movement of the toes is tested. Record this in the
comments section of the form in the free text field for ‘other’.

Peroneal nerve Tibial nerve

Test the peroneal nerve through dorsiflexion of the ankle and toes. Test the tibial nerve through plantar flexion of the ankle and toes.
Compartment syndrome

Pain
• Complications can be prevented when pain is identified and treated early.
• Pain can be caused by sensory nerve damage and/or diminished blood flow.
• Use a pain assessment tool to assess severity of pain. A hallmark of neurovascular compromise is pain
disproportionate to the injury.
• Note the location, severity, and areas of radiating pain.
• In sedated patients or those who can’t verbalize information, be aware of non-verbal pain cues including
grimacing, guarding, tachycardia, and hypotension.

Edema
• Edema can result from musculoskeletal injury, contribute to vascular compromise, and cause
damage to muscle and nerve tissue.
• Preexisting disease processes (i.e., heart failure, cirrhosis, or kidney disease) can place a patient at
increased risk for edema-related complications.
• Elevating the limb, no higher than heart level, can help decrease edema.
Frequency of Assessments
The frequency of performing a neurovascular assessment can vary within health care organizations and
across units, providers, diagnosis, or procedure. On average, if there is no change to a patient's condition,
neurovascular assessments typically default to every 4 hours. It is a best practice recommendation for
nurses to perform a neurovascular assessment together during handoff or a change in shift.

Risk Factors
Risk factors for increased neurovascular compromise may include (Schreiber, 2016; Judge, 2007):
• Musculoskeletal, nerve, or vascular injury
• Extremity infections, circumferential burns, or gunshot injuries
• Tissue edema
Compartment syndrome

• Fracture or surgery in limbs and joints

• Procedures that may cause limb thrombosis or emboli such as cardiac catheterization.
• Crush injury
• Prolonged immobility due to drug or alcohol induced coma
• Coagulation abnormalities
• History of peripheral vascular disease

Compartment syndrome
Acute compartment syndrome involves the compression of nerves and blood vessels within an enclosed
space. The compression leads to impaired blood flow and muscles and nerve damage. Compartment
syndrome may occur in an extremity as a complication of certain types of fractures, injuries and/or
procedures. If left untreated, irreversible damage to the muscle group and nerves can begin after only six
hours. In 24–48 hours, the extremity is rendered useless, and in extreme cases the limb will require
amputation.
Signs and symptoms
Any sign and symptom of acute compartment syndrome should be assessed and recorded, including
variation since previous assessment.
•Pain – Passive stretch of digits and/or limb can cause extreme pain, out of proportion to the injury and
unrelieved by analgesia. The pain is due to tissue hypoxia rather than trauma/surgery.
•Pallor (colour change) – Skin becomes pale and cool or cyanosed (discoloured and slightly blue) due to
venous congestion.
•Paralysis – Decreased or loss of movement due to nerve compression. Nerve compromise means that
nerves cannot innervate muscles. Muscles can survive 4–12 hours in a hypoxic state.
•Paraesthesia (changes in sensation) – Nerve hypoxia causes changes in sensation, such as a tingling or
prickling feeling. Nerves can survive 2–4 hours in a hypoxic state.
•Pulselessness – The absence of a pulse indicates serious compromise to the limb (late sign).
•Firm, tense, shiny skin – The skin over the muscle compartment can change.

Nursing management
•Notify the orthopaedic/specialty registrar or senior medical officer immediately.
•Elevate the affected limb to heart level only. Do not elevate above the heart level as this will decrease the
perfusion to the limb overall.2,9
•Reassess neurovascular status with another registered nurse or medical officer to confirm suspicion or
variation.
Compartment syndrome

•Apply ice if appropriate and if patient will tolerate it.

•Loosen any restrictive bandages or dressings. Increase the frequency of neurovascular assessment – at
minimum, perform half hourly until review.
•Place the patient nil by mouth until review (in case surgical intervention is required).
•Make the patient as comfortable as possible – provide reassurance and information.
•Ensure analgesia is administered.
•After consultation with the orthopaedic/specialty registrar or senior medical officer, split/cut tight
bandages/casts (plasters must be bivalve and underneath padding should be split to the skin).
•Document in the patient’s healthcare record. Include details about variations of neurovascular status and
effects of analgesia.