Management of Acute Compartment Syndrome

Col. Patrick M. Osborn, MD; Andrew H. Schmidt, MD


J Am Acad Orthop Surg. 2020;28(3):e108-e114. 

In This Article

Overview and Rationale

The American Academy of Orthopaedic Surgeons (AAOS), and the Major Extremity Trauma and Rehabilitation Consortium, with input from representatives from the Orthopaedic Trauma Association, the Society of Military Orthopaedic Surgeons, representatives from San Antonio Military Health System, and the U.S. Air Force Critical Care Air Transport Team, recently published their clinical practice guideline (CPG), Management of Acute Compartment Syndrome (ACS).[1] This CPG was approved by the AAOS Board of Directors in December 2018 and has been officially endorsed by the American College of Surgeons and the American Orthopaedic Foot & Ankle Society. The purpose of this CPG is to diagnose and treat ACS based on current best evidence.

The true incidence of ACS is unknown as the treatment, fasciotomy, essentially is the surrogate for determining the diagnosis. Although the economic burden of ACS is unknown, these injuries can result in prolonged hospital stays and increased costs compared with those without compartment syndrome. Developing ACS results in persistently poorer function and quality of life,[2] and there are substantial medicolegal implications in the diagnosis and treatment of compartment syndrome that affect patients, providers, and the healthcare system, alike.[3] Combat casualties shoulder a significant burden of the condition, with 15% of combat limb injuries resulting in fasciotomy,[4] but this cohort also showed a significant improvement in patient outcomes with greater focus on treating compartment syndrome. With appropriate education to treating surgeons and greater recognition of the potential diagnosis, US casualty mortality and need for revision surgery were decreased.[5]

Therefore, the Department of Defense partnered with the AAOS to develop an evidence-based, CPG to aid practitioners in the diagnosis and treatment of ACS.[1] Furthermore, the CPG represents a call for continued research to allow for more accurate and reliable diagnostic methods and treatments with less morbidity. An exhaustive literature search was conducted, resulting initially in over 200 articles for full review. The articles were then graded for quality and aligned with the workgroup's patients, interventions, and outcomes of concern. The workgroup used the established AAOS CPG methods to generate eight consensus statements regarding the diagnosis and treatment of compartment syndrome. Because of the lack of high-quality evidence, only six recommendations to guide diagnosis and one regarding management were made.

In summary, to create the ACS CPG, over 3,600 abstracts and more than 480 full-text articles were reviewed to develop 15 recommendations supported by publications meeting stringent inclusion criteria. Each recommendation is based on a systematic review of the research-related topic which resulted in three recommendations classified as moderate, four as limited, and eight consensus statements. The strength of recommendation is assigned based on the quality of the supporting evidence (Figure 1).

Figure 1.

Strength of recommendations categories.