## Clinical Diagnosis: Acute Compartment Syndrome with Crush Injury **Key Point:** Compartment syndrome is a surgical emergency requiring fasciotomy based on clinical signs, NOT pressure measurements alone. Pain out of proportion to findings is the hallmark. **High-Yield:** The classic "5 P's" are late findings; early diagnosis relies on: - Pain with passive stretch (most sensitive early sign) - Severe pain out of proportion - Tense compartment on palpation - Pulses may remain intact until late **Clinical Pearl:** In crush injuries, myoglobinuria (dark urine) indicates rhabdomyolysis and acute kidney injury risk. Aggressive IV hydration (target urine output 200–300 mL/hour) is mandatory to prevent renal failure. **Warning:** Waiting for compartment pressure measurement or using a 30 mmHg threshold delays definitive treatment. Clinical judgment (pain + exam findings) is the gold standard for fasciotomy indication. ### Management Algorithm ```mermaid flowchart TD A[Crush injury + severe pain on passive stretch]:::outcome --> B{Clinical signs of compartment syndrome?}:::decision B -->|Yes: pain out of proportion, tense compartment| C[Urgent fasciotomy]:::action B -->|Equivocal| D[Compartment pressure measurement]:::action D --> E{Pressure > 30 mmHg or Delta P < 30?}:::decision E -->|Yes| C E -->|No| F[Conservative management + serial exams]:::action C --> G[IV fluids, monitor urine output]:::action G --> H[Prevent rhabdomyolysis-induced AKI]:::outcome ``` **Mnemonic:** **CRAM** — **C**rush injury, **R**habdomyolysis, **A**cute compartment syndrome, **M**assive fluid resuscitation. [cite:Rockwood & Green's Fractures in Adults Ch 1] 
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