Management of Acute Compartment Syndrome

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

Disclosures

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

In This Article

Guideline Summary

Collectively, these recommendations create a framework for the evaluation of patients at risk of compartment syndrome with acute presentation and those with an unclear history as may be encountered with a crush injury after opioid overdose, certainly a growing concern.[6] The guidelines highlight the current limitations in diagnosing and treating ACS. The best evidence available suggests a role for certain biomarkers and repetitive compartment pressure monitoring as the most reliable adjuncts to diagnosis. Most questions regarding ACS have limited evidence or can only be addressed by a consensus statement from the workgroup. There are significant gaps in knowledge that highlight a critical need for further research.

This CPG provides orthopaedic surgeons and other physicians/providers evidence-based principles to guide the initial assessment and treatment of patients at risk of compartment syndrome. These recommendations inform the development of appropriate use criteria to standardize and improve the care of patients at risk of extremity compartment syndrome. The overview that follows describes the pertinent highlights and limitations of each recommendation. Describing the nuances of the supporting evidence associated with each recommendation provides context to aid appropriate application to patient care.

Laboratory tests (ie, biomarkers) are frequently used when compartment syndrome is suspected despite a lack of clearly demonstrated diagnostic benefit (Table 1). When evaluated from an evidence-based perspective, this CPG makes a limited recommendation based on one moderate-quality study[7] that myoglobinuria and serum troponin level may assist in diagnosing ACS. This study included traumatic and vascular causes of compartment syndrome, but not crush injury, and reported that elevated troponin levels were frequently used to decide on fasciotomy, but did not rule out the need for fasciotomy.[7] There is limited evidence that myoglobinuria does not assist in diagnosing ACS in patients with electrical injury.[8] In the very specific incidence of acute limb ischemia caused by femoral artery embolism, a moderate recommendation is made that femoral vein lactate concentration may assist in the diagnosis of ACS.[9] Additional evidence was also found regarding the role of biomarkers in two other clinical situations. A particular challenge is posed by patients who present with limb swelling or other signs of a possible crush injury of unknown duration or onset. No evidence was found to support using biomarkers to determine the presence of compartment syndrome in presumed missed cases or late presentation, so their use is not recommended to determine the safety of fasciotomy in these scenarios.

Measurement of intracompartmental pressure is a well-established method for diagnosing ACS; however, despite the ubiquitous literature on pressure measurement method, timing, and thresholds, only six studies of low to moderate quality met the standards for inclusion in this CPG (Table 2).[10–15] Similar to studies on physical examination and clinical findings, these studies used fasciotomy as a proxy for the diagnosis of ACS. The included studies further complicate concrete recommendations because of the variability in the thresholds for fasciotomy, timing, and method of pressure monitoring (single reading versus continuous versus serial measurement). Considered in whole, these articles provide moderate evidence that compartment pressure measurement assists in diagnosing ACS and that a perfusion pressure of greater than 30 mmHg is safe for ruling out compartment syndrome. Similar to physical examination findings alone, pressure-based thresholds for diagnosing ACS may result in overtreatment with fasciotomy. The workgroup recommends against using single pressure values alone for diagnosing compartment syndrome and suggests that clinical suspicion (the likelihood of compartment syndrome being present in the given clinical scenario) and the additional use of clinical examination findings also be considered. In the challenging situation of an adult patient with evidence of irreversible intracompartmental (neuromuscular/vascular) damage, such as muscle contracture or loss of normal neurologic function (neuromuscular/vascular) damage, such as muscle contracture, the workgroup agreed that compartment pressure monitoring does not provide useful information to guide decision making for fasciotomy.

Early diagnosis is essential and should be driven by a high index of suspicion based on the clinical history. In the setting of limb trauma, physical examination has traditionally been considered the primary method of diagnosis (Table 3). However, the published evidence regarding the diagnostic performance of clinical findings in the setting of ACS is quite limited. Therefore only a limited recommendation supports serial physical examination to diagnose ACS in awake patients due to poor specificity.[10,11,14] The sensitivity of these signs is also suboptimal, as they can be missed or attributed to other aspects of injury. In obtunded patients, the workgroup found no evidence regarding the utility of the clinical examination in diagnosing ACS. Therefore, the workgroup's consensus was that pressure-based methods of diagnosis be used.

Recognizing the limitations of physical examination in the diagnosis of ACS, alternative, less-invasive methods for diagnosing compartment syndrome are sought (Table 4). Numerous articles on potential diagnosis methods such as objective determination of limb hardness or use of alternative technologies such as near-infrared spectroscopy, electromyography, and pH testing have been published. However, at this time, there is no evidence that other reported diagnostic modalities provide useful information to guide decision making when considering fasciotomy.

When considering treatment (Table 5), no definitive evidence supports a specific method of fasciotomy (eg, one or two incisions), given that complete decompression of the affected compartments is achieved. When fasciotomy is performed, there is a limited recommendation for negative pressure wound dressings to reduce the time to final closure and need for skin grafting.[16–19] In adult patients with evidence of irreversible intracompartmental injury, the consensus of the workgroup was that fasciotomy is not indicated. Furthermore, in such a circumstance, if fracture stabilization is needed, the surgeon should consider a technique that does not violate the involved compartment. In contrast, the consensus of the workgroup was that in patients with ACS undergoing fasciotomy, standard methods of stabilization, including internal fixation, can be used. The workgroup also hoped to address the question of whether neuraxial anesthetic techniques might affect the diagnosis of ACS in awake patients by masking the clinical symptoms. No literature was found that addressed this scenario, and the consensus opinion of the workgroup is that neuraxial anesthesia may complicate the clinical diagnosis of ACS. The workgroup further recommends that if neuraxial anesthesia is administered in a patient at risk of developing ACS, frequent physical examination and/or pressure monitoring should be performed.

In summary, this guideline summarizes the current published evidence regarding the diagnosis and treatment of both acute and late-presenting extremity compartment syndrome. The recommendations in this guideline are not intended to be used as part of a rigid management protocol, and as with all evidence-based recommendations, practitioners must also rely on their clinical judgment and experience as well as their patients' and their families' preferences and values when making treatment decisions. A number of important clinical questions considered in the development of this CPG could not be answered in an evidence-based fashion, but the consensus opinion of the CPG workgroup still provides important information for clinicians to consider for their own practice. The dearth of high-quality research precluded the group from making any strong recommendations regarding diagnosis and treatment. However, the group was unanimous in its call for additional research to improve current evidence and increase our understanding of extremity compartment syndrome. As part of a continuous improvement cycle, new data will emerge that further defines the role of current diagnostic and treatment strategies and new methods of care. Clinicians will need to continually evaluate new information, interpret it according to evidence-based medicine standards, and then use any new information to adjust and optimize care for their patients. It is also important that the utility of these guidelines in patient care be validated.

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