Focus On

Diagnosis of acute
compartment syndrome
Acute compartment syndrome (ACS) is defned by a critical
pressure increase within a confned compartmental space,
causing a decline in the perfusion pressure to the compartment
tissue,
1-6
which without timely diagnosis and treatment will
lead to ischaemia, necrosis and ultimately permanent disability
of the affected region.
6-9
Management is with immediate
fasciotomy and decompression of all tissues within the affected
compartment.
6,10-13

Principles Of Diagnosis
The diagnosis of ACS throughout the literature often uses a
combination of clinical signs and/or compartment pressure
monitoring, with a recent systematic review on compartment
syndrome of the forearm documenting the use of monitoring
in 50% of cases.
6,14-16
OToole et al
17
documented that
compartment pressure monitoring was only used as the
primary diagnostic tool in 11.7% of cases when they reviewed
the notes of 386 tibial diaphyseal fractures at a large
level I trauma centre. An older United Kingdom survey of
compartment pressure monitoring revealed that over 50% of all
consultant orthopaedic surgeons did not use monitoring within
their institution.
14

A delay in the diagnosis and management of ACS leads to
a prolonged time of inadequate perfusion and has been found
to result in a poor outcome for the patient,
10,13,18-20
as well as
being associated with increased medical costs.
21
A prompt
diagnosis is necessary to minimise the risk in a predominantly
young and active population of potentially devastating long-
term complications such as muscle necrosis, contractures,
neurological defcits, fracture nonunion, infection, chronic pain,
and in the worst cases amputation and even death.
6,10,16,22-24

Along with providing an improved patient outcome, an early
diagnosis is associated with decreased indemnity risk for legal
claims.
25
A delay in diagnosis has been attributed to a lack
of awareness for the condition, inexperience of the surgeon,
general or regional anaesthesia, patients with polytrauma, soft-
tissue injuries and the reliance solely on the clinical signs used
to diagnose ACS.
6,24,26-32
Epidemiology And Demographic Risk Factors
Knowledge of the incidence, and an understanding of the
demographic risk factors, is invaluable when assessing a
patient for a suspected ACS. The annual incidence of ACS in
the literature has been quoted as 3.1 per 100 000 population,
with the incidence in males ten times that of females.
15,16
The
mean age ranges from 30 to 35 years with males affected
at a signifcantly younger age than females.
15,33,34
The most
frequently affected sites are the leg
13,20,35,36
and forearm,
16,37-39

although the arm,
40-43
hand,
43-45
gluteal region,
32,46
thigh,
24,47-50

foot
51-55
and abdomen
56
can all be affected.
Over two-thirds of all ACS presentations are associated
with a fracture, with a tibial diaphyseal fracture accounting
for a third of all ACS cases (Table I).
15
In the early days of
intramedullary nailing of tibial diaphyseal fractures there was
some concern that the technique might cause an increased
rate of ACS,
19,57-61
but subsequent studies have documented
no increase in incidence.
61,62
The incidence of ACS associated
with a fracture of the tibia or distal radius has been found
to be signifcantly increased in patients under the age of 35
years at the time of injury.
15
In a large study of 1403 fractures
of the tibial shaft from Edinburgh, risk factors for developing
ACS were identifed as male gender and youth.
6
Furthermore,
in a recent study of 414 tibial fractures, risk factors for the
development of ACS were young patients with diaphyseal
fractures.
63
A proposed explanation for this is related to the
increased muscle size in these patients, and hence a reduced
capacity for swelling. In elderly patients, the protective effects
of an increased perfusion pressure (hypertension) and small
atrophied muscles has been postulated.
Although commonly associated with fractures, it is important
to appreciate that almost a quarter of ACS presentations arise
in the absence of a fracture.
15,16,23
The mean age of patients
who develop an ACS associated with a soft-tissue injury is
signifcantly older than those associated with a fracture.
23

A variety of causes has been identifed and includes crush
injuries, crush syndrome, drug overdose and anti-coagulation
therapy.
15,22,24,34,37,48,49,55,64-66
ACS in the absence of fracture
has been found to be associated with a delay to diagnosis and
fasciotomy.
23

High-energy injuries including sports, road traffc accident
and falls from height accounted for only half of all the modes
of injury in one study of ACS.
15
Although commonly perceived
to be associated with high-energy injuries and open fractures,
data has demonstrated an increased rate of ACS complicating
closed low energy tibial diaphyseal fractures.
15,67-69
This is
perceived to be related to the auto-decompression of the
2011 British Editorial Society of Bone and Joint Surgery 1
THE JOURNAL OF BONE AND JOINT SURGERY
2 A. D. DUCKWORTH, M. M. MCQUEEN
affected compartment at the time of a high energy injury.
However, high energy fractures of the forearm and femur are
associated with an increased rate of ACS, which is probably
related to the high number of young males who sustain these
injuries.
15,16,43,48

Clinical Diagnosis
Symptoms and signs associated with a diagnosis of ACS are
pain out of proportion to the injury, pain on passive stretch,
swelling, sensory disturbance and motor disturbance.
Weakness or absence of peripheral pulses is not an associated
sign as this indicates either a vascular injury or the late stages
of ACS, in which scenario amputation is usually necessary.
6

A clinical diagnosis can be made on a combination of these
clinical signs. However, there is literature documenting the poor
diagnostic performance characteristics of these signs,
28
and
they have been felt to be unreliable in the assessment of ACS in
adults
6,24,51,54,70
and in children.
71
Ulmer
28
performed a systematic review to determine the
effcacy of four clinical signs in the diagnosis of ACS (Table II).
He found that the sensitivity of clinical fndings for diagnosing
ACS to be low at 13% to 19%, with a specifcity of 97% (Table
II), and concluded that all the signs are better at excluding than
confrming a diagnosis. In this analysis, it was found that with
only one positive sign, the odds of ACS being present never
reached above 26%. With three positive signs the odds were
93%, however, the third sign was paresis. This is a late sign of
ACS and it is not acceptable to wait for this to develop before
making the diagnosis and instituting treatment. If the diagnosis
is delayed until paresis is established only 13% of patients will
make a full recovery.
35

Pain. Severe pain that is out of proportion to the associated
injury and refractory to analgesia is judged to be the primary
symptom of ACS. However, pain is subjective, already present
post injury, of variable intensity, can be reduced when affecting
the deep posterior compartment, can be absent when there is
a concomitant nerve injury, and has been found to have very
poor sensitivity (Table II).
13,18,22,28,72
It has also been proven to
be inadequate when assessing children or in the patient with
poly-trauma and suspected ACS.
71,73
Pain on passive stretch
is equally unreliable with comparable diagnostic performance
characteristics (Table II).
28,72,74
Badhe et al
74
reported four cases
of ACS in which any form of pain was absent, with diagnosis
confrmed on subsequent fasciotomy.
Swelling. Although palpable swelling is a common presenting
feature of ACS, it is a very subjective sign and is often hindered
due to either the necessity of immobilisation masking the
affected compartment or the fact that some compartments are
deep and therefore diffcult to assess.
18,75

Paraesthesia. This sign can be related to either nerve
ischaemia as it runs through the affected compartment or can
be related to a concomitant nerve injury.
72,76
There were initial
suggestions that this sign might be more useful than pain in
the diagnosis of ACS
75
but it has since been suggested this is a
late sign.
20
On analysis, sensitivity is even lower at 13%, with a
marginally increased specifcity (98%).
28
Paralysis/Paresis. This is a late sign of ACS and is the
poorest performing clinical fnding on diagnostic performance
analysis.
28
Positive pre-fasciotomy motor symptoms have been
found to negatively infuence the outcome in patients with
compartment syndrome,
12,35,48
with one study reporting that
only 13% of patients achieve a full recovery.
35
Furthermore,
there is noted diffculty in determining the presence of limb
paralysis in a trauma patient who may have limited motor
function due to pain.
77
Compartment Pressure Monitoring
Given the necessity for a timely diagnosis, the variable
aetiology and presentation of ACS, as well as the poor
performing diagnostic performance characteristics of the
clinical signs at presentation, continuous intracompartmental
pressure (ICP) monitoring in all at risk patients is
recommended.
6,13,15,23,28,31,74,78-81
Pressure monitoring has
been proven to detect ACS prior to the onset of clinical
signs in addition to reducing the time to fasciotomy and the
development of subsequent sequelae,
13,82
whilst not increasing
the rate of fasciotomy or associated complications.
69,83-85
McQueen, Christie and Court-Brown
13
reviewed 25 patients
(13 monitored, 12 not monitored) with tibial diaphyseal
fractures that had been complicated by an ACS. They found a
signifcant increase in the time from injury to fasciotomy (16
Cause % of cases
Fracture
Tibial diaphyseal fracture 36
Distal radius fracture 9.8
Diaphyseal forearm fracture 7.9
Femoral diaphyseal fracture 3.0
Tibial plateau fracture 3.0
Soft tissue
Soft-tissue injury 23.2
Crush syndrome 7.9
Table I. Conditions associated with the development of acute
compartment syndrome
15
Table II. The diagnostic performance characteristics of the
frequently employed clinical signs of acute compartment
syndrome as found by Ulmer
28
(PPV, positive predictive value;
NPV, negative predictive value)
Pain Pain on
passive stretch
Paraesthesia Paresis
Sensitivity (%) 19 19 13 13
Specifcity (%) 97 97 98 97
PPV (%) 14 14 15 11
NPV (%) 98 98 98 98
3 DIAGNOSIS OF ACUTE COMPARTMENT SYNDROME
hour difference, p < 0.05), no complications in the monitored
group compared with 83% in the non-monitored (p < 0.01), and
a signifcant delay in tibial union in the non-monitored group (p
< 0.05).
13
Al-Dadah et al
85
compared 109 patients with a tibial
diaphyseal fracture who underwent continuous ICP monitoring
(fasciotomy rate 15.6%, time to fasciotomy 22 hours) with a
historical control group of 109 patients who were assessed
using clinical signs alone (fasciotomy rate 14.7%, time to
fasciotomy 23 hours). Although they found no signifcant
increase in the fasciotomy rate, they did not demonstrate a
signifcant difference in terms of clinical outcome or time to
fasciotomy.
85
Harris, Kadir and Donald
86
performed a randomised trial of
200 consecutive tibial fractures comparing monitored and non-
monitored patients. The primary outcome measure was the
presence of late sequelae by six months after injury. According
to the protocol, monitored patients underwent continuous
ICP monitoring for 36 hours (no cases of ACS) and the non-
monitored group received standard clinical assessment (fve
cases of ACS). They documented no difference between groups
regarding the complication rates recording 27 soft-tissue
complications and 29 nonunions in the 177 patients available
for review.
86
A criticism of this study is that like was compared
with like as the indication for fasciotomy in alert patients in
both groups was clinical symptoms and signs.
86
Furthermore,
issues regarding timing were ignored. For the ICP monitoring
to be compared accurately with clinical symptoms and signs it
must be the primary indication for fasciotomy.
Methods of ICP monitoring (Table III). Techniques for ICP
monitoring include indirect measures using the needle
manometer with or without the infusion of saline into the
compartment,
11,87,88
the wick catheter,
75,89
the slit catheter
90-92
or
the solid state transducer intracompartmental catheter (STIC)
with or without the transducer at the tip.
78,93,94
The slit catheter
is currently recommended and used by many authors, including
within our unit.
13,69,90
Boody and Wongworawat
95
compared three ICP monitoring
devices (Stryker ICP pressure monitor, Whitesides apparatus,
arterial line manometer) using an in vitro model. They
concluded that side-port needles and slit catheters were more
accurate than straight needles, with the arterial line manometer
and the Stryker monitor the most accurate devices.
95
Collinge
and Kuper
96
performed a clinical study in 26 patients with
suspected ACS (31 limbs, 97 compartments) to compare three
ICP monitoring devices (STIC, electronic transducer-tipped
catheter, modifed Whitesides needle). They concluded all
techniques were comparable but not completely reliable for ICP
monitoring in trauma patients.
96
Innovative techniques include near infrared spectroscopy,
which is a direct non-invasive measure of tissue oxygenation
and has demonstrated good correlation with ICP measurements
in both experimental and human studies,
97-100
though further
work is required.
Technique and placement. Whichever method of ICP
monitoring is employed, appropriate placement is within or on
the affected compartment using an aseptic technique.
101
In
the presence of an associated fracture, the device should be
Technique Pros Cons
Needle manometer Simple
Cheap
Poor accuracy
Indirect measure
Invasive
Continuous measurement not possible
Fluid infusion may worsen ACS
Needle tip may block
False positives and negatives documented
Wick catheter Good accuracy
Large surface area
Obstruction of catheter rare
Continuous monitoring
Indirect measure
Invasive
Blockage at air/fuid junction
Retention of wick material
Transducer must be at level of catheter
Slit catheter Good accuracy
Large surface area
Continuous monitoring
Indirect measure
Invasive
False low reading with air bubbles
Obstruction of catheter can occur
Transducer must be at level of catheter
Solid state transducer
intracompartmental catheter (STIC)
Good accuracy
Continuous monitoring
No issues with transducer level
Indirect measure
Invasive
Increased expense
Requires heparinised saline
Requires re-sterilisation
Near infrared spectroscopy Good accuracy and correlation
Continuous monitoring
Non-invasive
Increased expense
Validation undetermined for ACS
Variable reading with varying depth of soft tissues
Table III. The advantages and disadvantages for the techniques available for intracompartmental pressure monitoring in acute compartment
syndrome (ACS)
62,69,75,78,87,89-100,118-120
THE JOURNAL OF BONE AND JOINT SURGERY
4 A. D. DUCKWORTH, M. M. MCQUEEN
placed within 5 cm of the level of the fracture to give accurate
readings.
6,80,102,103
In the leg, the anterior compartment is routinely used as it
is the most frequently affected and accessible.
69,85
However,
despite being potentially diffcult to manage and uncomfortable
for the patient, some authors do recommend monitoring the
deep posterior compartment as well given the associated
risk of missing an isolated deep ACS.
18,102
We would routinely
recommend this if there is a clinical reason to suspect its
presence. For other suspected compartment syndromes
of the lower limb, the anterior compartment of the thigh is
recommended as it has been found to be most frequently
affected.
24,47-50
Isolated posterior thigh compartment syndromes
have been reported and should always be excluded.
104
In the
case of a suspected foot ACS, the interosseous compartments
are suggested, with consideration of the calcaneal
compartment in hindfoot injuries.
51,54,55
The forearm is the most commonly affected site in the
upper limb and measurement of the fexor compartment is
routine.
16,22,37,39,43,105,106
Again, in the suspected case of a rare
isolated dorsal ACS, that compartment should be measured.
16

The anterior compartment of the arm and the interosseous
compartment of the hand are the recommended placements
for ICP monitoring for the remainder of the upper limb.
6,41,43,44
Threshold and timing for decompression. Evidence has
demonstrated that the normal ICP of healthy muscle is 10
mmHg.
107
Much of the literature attempting to determine
the threshold pressure for decompression has focused on
whether to use ICP alone or whether to consider the ICP
in relation to perfusion pressure. Despite initial studies
suggesting an absolute ICP of 30-50 mmHg to be the
threshold,
12,44,68,75,83,87,108
it is now recognised that a patients
tolerance to the ICP is dependent on perfusion, or the systemic
blood pressure.
69,103,109-111
Whitesides et al
109
was the frst to
suggest this using an animal model, with ranges from 10 mmHg
to 35 mmHg considered diagnostic.
103,111,112
However, there
is now experimental and clinical work suggesting a pressure
difference or delta pressure (P = diastolic pressure intra-
compartmental pressure) of less than or equal to 30 mmHg
should be considered diagnostic.
13,69,82,101
McQueen and Court-
Brown
69
studied 116 patients with tibial diaphyseal fractures
who underwent continuous pressure monitoring of the anterior
compartment for 24 hours. The use of a P of 30 mmHg
as a threshold for fasciotomy led to no missed cases of ACS,
no unnecessary fasciotomies and no complications in any
patients.
69
White et al
101
validated the clinical use of a P of
30 mmHg in a study of 101 patients followed for over a one
year period. They found no signifcant difference in muscle
power or return to function in 41 patients with an absolute
pressure of over 30 mmHg and a P over 30 mm Hg for more
than six hours continuously, with the 60 patients who had
absolute pressures of less than 30 mmHg.
101
It should be noted that much of the above work does not
include children and was carried out solely in association with
ACS of the leg. Other regions of the body may have different
pressure thresholds but in the absence of evidence to the
contrary it seems reasonable to retain the threshold of a P of
30 mmHg. Furthermore, in children, the mean arterial pressure
rather than the diastolic pressure has been suggested a more
appropriate measure to calculate the P as the diastolic
pressure is often lower in this group of patients.
113
Confusion in the literature regarding time to fasciotomy
relates to the defnition of the start point. Time to fasciotomy
has been found to correlate with outcome,
10,13,18-20
with six to
12 hours quoted as critical in both clinical and experimental
studies.
83,108,114,115
The variation is likely to be due to varying
pressure levels. It is probable that a lower pressure can be
tolerated for a longer period of time and vice versa.
108,115
We
would suggest that time to fasciotomy would be most accurately
determined as time from admission as this is closest to the
time of injury.
6,23,69
Time from diagnosis is not relevant as once
the diagnosis has been made, urgent fasciotomy should be
performed without delay.
When using ICP monitoring, the trend and duration of
pressure measurements are important to consider when
determining the appropriate point to perform fasciotomy.
6,62

By employing a protocol of fasciotomy to be carried out based
on the trend of readings over a two hour period, authors have
found a reduction in the time to fasciotomy and complications
whilst not increasing the rate of fasciotomy.
69
One study has
suggested overtreatment can occur with continuous ICP
monitoring,
116
although this study does not consider the trend
over time. A diagnosis of ACS should not be made on the
basis of a single reading. Another consideration is the effect
of anaesthesia on blood pressure. Kakar et al
117
performed a
prospective cohort study of 242 tibial fractures treated with
intramedullary nail fxation under GA. When calculating the P
using ICP monitoring, they found the pre-operative diastolic
pressure correlated well with the post-operative pressure, with
a signifcant difference seen in the intra-operative pressure
(mean difference 18 mmHg, p < 0.05).
117
They concluded
that fasciotomy should not be performed on an isolated P
measurement intra-operatively and that serial measurements
are recommended.
Future Work
The literature would beneft from further long-term outcome
studies examining the usefulness and effect of ICP monitoring,
as well as data on the diagnostic performance characteristics
of ICP monitoring. Further work is needed to determine the
critical P for other regions of the body and in children, as well
as more data on the innovative techniques of ICP monitoring.
5 DIAGNOSIS OF ACUTE COMPARTMENT SYNDROME
Large prognostic prospective studies would help identify
and clarify high-risk patients. Optimally, adequately powered
prospective randomised controlled trials of continuous
ICP monitoring versus clinical signs would provide level 1
evidence. However, several issues arise with this. Firstly,
for ICP monitoring to be effective it needs to be the primary
indicator for fasciotomy including consideration of time factors.
Secondly, during the conduct of any such trial there is a high
risk of changing behaviour by encouraging more stringent and
frequent examination of the patient than is normal practice,
thus biasing the results. Thirdly, there is no gold standard
reference for diagnosing ACS and the incidence in the literature
is quoted as well below 30%.
15,17,63
In this situation, statistical
methodology including latent class analysis and Bayes theorem
should be used when determining the diagnostic performance
characteristics of the clinical tests used.
Conclusions
In conclusion, acute compartment syndrome can occur
following either a fracture or soft tissue injury, with males
and youth being most at risk. Because of the poor diagnostic
performance characteristics of the clinical diagnosis, we would
recommend continuous compartment pressure monitoring as
the prime diagnostic tool in the following situations:
All patients with tibial diaphyseal fractures
All patients with high-energy tibial pilon and plateau
fractures
All young patients with high-energy forearm or femoral
injuries, with or without an associated fracture
All patients with soft tissue swelling suggestive of
compartment syndrome, irrespective of age, gender or
causality
All patients at risk who are unable to co-operate with clinical
assessment (e.g. patients with polytrauma, ventilated
patients, children)
Until further evidence is available, we would recommend the slit
catheter technique for continuous ICP monitoring, with a P of
30 mmHg diagnostic of ACS using a trend of readings over a
two hour period.
Andrew D. Duckworth MSc, MRCS Ed Specialty Registrar and
Clinical Research Fellow
Margaret M. McQueen MD, FRCSEd(Orth) Professor of
Orthopaedic Trauma
Edinburgh Orthopaedic Trauma Unit, Royal Infrmary of
Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU
E-mail: andrew.duckworth@yahoo.co.uk
References
1. Ashton H. Critical closing pressure in human peripheral vascular beds. Clin Sci
1962;22:79-87.
2. Ashton H. The effect of increased tissue pressure on blood fow. Clin Orthop 1975:15-
26.
3. Matsen FA 3rd, Krugmire RB Jr. Compartmental syndromes. Surg Gynecol Obstet
1978;147:943-9.
4. Matsen FA 3rd, King RV, Krugmire RB Jr, Mowery CA, Roche T. Physiological
effects of increased tissue pressure. Int Orthop 1979;3:237-44.
5. Hartsock LA, OFarrell D, Seaber AV, Urbaniak JR. Effect of increased
compartment pressure on the microcirculation of skeletal muscle. Microsurgery
1998;18:67-71.
6. McQueen MM. Acute compartment syndrome. In: Bucholz RW, Court-Brown CM,
Heckman JD, Tornetta P 3rd, eds. Rockwood and Greens Fractures in Adults. Seventh ed.
Philadelphia: Lippincott Williams & Wilkins, 2010:689-708.
7. Gelberman RH, Zakaib GS, Mubarak SJ, Hargens AR, Akeson WH.
Decompression of forearm compartment syndromes. Clin Orthop 1978;134:225-9.
8. Holden CE. The pathology and prevention of Volkmanns ischaemic contracture. J
Bone Joint Surg [Br] 1979;61-B:296-300.
9. Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome: course
after delayed fasciotomy. J Trauma 1996;40:342-4.
10. Sheridan GW, Matsen FA 3rd. Fasciotomy in the treatment of the acute
compartment syndrome. J Bone Joint Surg [Am] 1976;58-A:112-15.
11. Matsen FA 3rd, Winquist RA, Krugmire RB Jr. Diagnosis and management of
compartmental syndromes. J Bone Joint Surg [Am] 1980;62-A:286-91.
12. Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint
Surg [Br] 1984;66-B:93-7.
13. McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in
tibial diaphyseal fractures. J Bone Joint Surg [Br] 1996;78-B:95-8.
14. Williams PR, Russell ID, Mintowt-Czyz WJ. Compartment pressure monitoring:
current UK orthopaedic practice. Injury 1998;29:229-32.
15. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome: who
is at risk? J Bone Joint Surg [Br] 2000;82-B:200-3.
16. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment syndrome of
the forearm: a systematic review. J Hand Surg Am 2011;36:535-43.
17. OToole RV, Whitney A, Merchant N, et al. Variation in diagnosis of compartment
syndrome by surgeons treating tibial shaft fractures. J Trauma 2009;67:735-41.
18. Matsen FA 3rd, Clawson DK. The deep posterior compartmental syndrome of the
leg. J Bone Joint Surg [Am] 1975;57-A:34-9.
19. Mullett H, Al-Abed K, Prasad CV, OSullivan M. Outcome of compartment
syndrome following intramedullary nailing of tibial diaphyseal fractures. Injury
2001;32:411-13.
20. Rorabeck CH, Macnab L. Anterior tibial-compartment syndrome complicating
fractures of the shaft of the tibia. J Bone Joint Surg [Am] 1976;58-A:549-50.
21. Schmidt AH. The impact of compartment syndrome on hospital length of stay and
charges among adult patients admitted with a fracture of the tibia. J Orthop Trauma
2011;25:355-7.
22. Eaton RG, Green WT. Volkmanns ischemia: a volar compartment syndrome of the
forearm. Clin Orthop 1975;113:58-64.
23. Hope MJ, McQueen MM. Acute compartment syndrome in the absence of fracture.
J Orthop Trauma 2004;18:220-4.
THE JOURNAL OF BONE AND JOINT SURGERY
6 A. D. DUCKWORTH, M. M. MCQUEEN
24. Mithofer K, Lhowe DW, Vrahas MS, Altman DT, Altman GT. Clinical spectrum
of acute compartment syndrome of the thigh and its relation to associated injuries. Clin
Orthop 2004;425:223-9.
25. Bhattacharyya T, Vrahas MS. The medical-legal aspects of compartment
syndrome. J Bone Joint Surg [Am] 2004;86-A:864-8.
26. Mubarak SJ, Wilton NC. Compartment syndromes and epidural analgesia. J
Pediatr Orthop 1997;17:282-4.
27. Harrington P, Bunola J, Jennings AJ, Bush DJ, Smith RM. Acute compartment
syndrome masked by intravenous morphine from a patient-controlled analgesia pump.
Injury 2000;31:387-9.
28. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are
clinical fndings predictive of the disorder? J Orthop Trauma 2002;16:572-7.
29. Richards H, Langston A, Kulkarni R, Downes EM. Does patient controlled
analgesia delay the diagnosis of compartment syndrome following intramedullary nailing
of the tibia? Injury 2004;35:296-8.
30. Davis ET, Harris A, Keene D, Porter K, Manji M. The use of regional anaesthesia
in patients at risk of acute compartment syndrome. Injury 2006;37:128-33.
31. Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower
limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth 2009;102:3-11.
32. Roberts CS, Gorczyca JT, Ring D, Pugh KJ. Diagnosis and treatment of less
common compartment syndromes of the upper and lower extremities: current evidence
and best practices. Instr Course Lect 2011;60:43-50.
33. Simpson NS, Jupiter JB. Delayed onset of forearm compartment syndrome: a
complication of distal radius fracture in young adults. J Orthop Trauma 1995;9:411-18.
34. Morin RJ, Swan KG, Tan V. Acute forearm compartment syndrome secondary to
local arterial injury after penetrating trauma. J Trauma 2009;66:989-93.
35. Bradley EL 3rd. The anterior tibial compartment syndrome. Surg Gynecol Obstet
1973;136:289-97.
36. Halpern AA, Nagel DA. Anterior compartment pressures in patients with tibial
fractures. J Trauma 1980;20:786-90.
37. Gelberman RH, Garfn SR, Hergenroeder PT, Mubarak SJ, Menon J.
Compartment syndromes of the forearm: diagnosis and treatment. Clin Orthop 1981:252-
61.
38. Peters CL, Scott SM. Compartment syndrome in the forearm following fractures of
the radial head or neck in children. J Bone Joint Surg [Am] 1995;77-A:1070-4.
39. Botte MJ, Gelberman RH. Acute compartment syndrome of the forearm. Hand Clin
1998;14:391-403.
40. Vitale GC, Richardson JD, George SM Jr, Miller FB. Fasciotomy for severe,
blunt and penetrating trauma of the extremity. Surg Gynecol Obstet 1988;166:397-401.
41. Diminick M, Shapiro G, Cornell C. Acute compartment syndrome of the triceps
and deltoid. J Orthop Trauma 1999;13:225-7.
42. Prasarn ML, Ouellette EA, Livingstone A, Giuffrida AY. Acute pediatric
upper extremity compartment syndrome in the absence of fracture. J Pediatr Orthop
2009;29:263-8.
43. Prasarn ML, Ouellette EA. Acute compartment syndrome of the upper extremity. J
Am Acad Orthop Surg 2011;19:49-58.
44. Halpern AA, Greene R, Nichols T, Burton DS. Compartment syndrome of the
interosseous muscles: early recognition and treatment. Clin Orthop 1979;140:23-5.
45. Schnall SB, Holtom PD, Silva E. Compartment syndrome associated with infection
of the upper extremity. Clin Orthop 1994;306:128-31.
46. Brumback RJ. Traumatic rupture of the superior gluteal artery, without fracture of
the pelvis, causing compartment syndrome of the buttock: a case report. J Bone Joint
Surg [Am] 1990;72-A:134-7.
47. Tarlow SD, Achterman CA, Hayhurst J, Ovadia DN. Acute compartment
syndrome in the thigh complicating fracture of the femur: a report of three cases. J Bone
Joint Surg [Am] 1986;68-A:1439-43.
48. Schwartz JT Jr, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of
the thigh: a spectrum of injury. J Bone Joint Surg [Am] 1989;71-A:392-400.
49. Mithfer K, Lhowe DW, Altman GT. Delayed presentation of acute compartment
syndrome after contusion of the thigh. J Orthop Trauma 2002;16:436-8.
50. Mithoefer K, Lhowe DW, Vrahas MS, et al. Functional outcome after acute
compartment syndrome of the thigh. J Bone Joint Surg [Am] 2006;88-A:729-37.
51. Myerson M. Diagnosis and treatment of compartment syndrome of the foot.
Orthopedics 1990;13:711-17.
52. Manoli A 2nd, Weber TG. Fasciotomy of the foot: an anatomical study with special
reference to release of the calcaneal compartment. Foot Ankle 1990;10:267-75.
53. Kym MR, Worsing RA Jr. Compartment syndrome in the foot after an inversion
injury to the ankle: a case report. J Bone Joint Surg [Am] 1990;72-A:138-9.
54. Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal
fractures. Clin Orthop 1993;290:142-50.
55. Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment
syndrome of the lower leg and foot. Clin Orthop 2010;468:940-50.
56. Saggi BH, Sugerman HJ, Ivatury RR, Bloomfeld GL. Abdominal compartment
syndrome. J Trauma 1998;45:597-609.
57. Tischenko GJ, Goodman SB. Compartment syndrome after intramedullary nailing
of the tibia. J Bone Joint Surg [Am] 1990;72-A:41-4.
58. Moed BR, Strom DE. Compartment syndrome after closed intramedullary nailing of
the tibia: a canine model and report of two cases. J Orthop Trauma 1991;5:71-7.
59. Koval KJ, Clapper MF, Brumback RJ, et al. Complications of reamed
intramedullary nailing of the tibia. J Orthop Trauma 1991;5:184-9.
60. Williams J, Gibbons M, Trundle H, Murray D, Worlock P. Complications of
nailing in closed tibial fractures. J Orthop Trauma 1995;9:476-81.
61. Tornetta P 3rd, French BG. Compartment pressures during nonreamed tibial nailing
without traction. J Orthop Trauma 1997;11:24-7.
62. McQueen MM, Christie J, Court-Brown CM. Compartment pressures after
intramedullary nailing of the tibia. J Bone Joint Surg [Br] 1990;72-B:395-7.
63. Park S, Ahn J, Gee AO, Kuntz AF, Esterhai JL. Compartment syndrome in tibial
fractures. J Orthop Trauma 2009;23:514-18.
64. Mubarak S, Owen CA. Compartmental syndrome and its relation to the crush
syndrome: a spectrum of disease: a review of 11 cases of prolonged limb compression.
Clin Orthop 1975;113:81-9.
65. Reis ND, Michaelson M. Crush injury to the lower limbs: treatment of the local
injury. J Bone Joint Surg [Am] 1986;68-A:414-18.
66. Geary N. Late surgical decompression for compartment syndrome of the forearm. J
Bone Joint Surg [Br] 1984;66-B:745-8.
67. DeLee JC, Stiehl JB. Open tibia fracture with compartment syndrome. Clin Orthop
1981;160:175-84.
68. Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim NA. Compartment
syndrome in open tibial fractures. J Bone Joint Surg [Am] 1986;68-A:1348-53.
69. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures: the
7 DIAGNOSIS OF ACUTE COMPARTMENT SYNDROME
pressure threshold for decompression. J Bone Joint Surg [Br] 1996;78-B:99-104.
70. Whitesides TE, Heckman MM. Acute compartment syndrome: update on
diagnosis and treatment. J Am Acad Orthop Surg 1996;4:209-18.
71. Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children:
contemporary diagnosis, treatment, and outcome. J Pediatr Orthop 2001;21:680-8.
72. Wright JG, Bogoch ER, Hastings DE. The occult compartment syndrome. J
Trauma 1989;29:133-4.
73. Kosir R, Moore FA, Selby JH, et al. Acute lower extremity compartment syndrome
(ALECS) screening protocol in critically ill trauma patients. J Trauma 2007;63:268-75.
74. Badhe S, Baiju D, Elliot R, Rowles J, Calthorpe D. The silent compartment
syndrome. Injury 2009;40:220-2.
75. Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH. Acute
compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J
Bone Joint Surg [Am] 1978;60-A:1091-5.
76. Robinson CM, ODonnell J, Will E, Keating JF. Dropped hallux after the
intramedullary nailing of tibial fractures. J Bone Joint Surg [Br] 1999;81-B:481-4.
77. Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint
Surg [Br] 2003;85-B:625-32.
78. McDermott AG, Marble AE, Yabsley RH, Phillips MB. Monitoring dynamic
anterior compartment pressures during exercise: a new technique using the STIC
catheter. Am J Sports Med 1982;10:83-9.
79. Heppenstall B, Tan V. Well-leg compartment syndrome. Lancet 1999;354:970.
80. Saikia KC, Bhattacharya TD, Agarwala V. Anterior compartment pressure
measurement in closed fractures of leg. Indian J Orthop 2008;42:217-21.
81. McQueen MM, Court-Brown CM. Early diagnosis of compartment syndrome:
continuous pressure measurement or not? Injury 2010;41:431-2.
82. Ozkayin N, Aktuglu K. Absolute compartment pressure versus differential pressure
for the diagnosis of compartment syndrome in tibial fractures. Int Orthop 2005;29:396-
401.
83. Allen MJ, Stirling AJ, Crawshaw CV, Barnes MR. Intracompartmental pressure
monitoring of leg injuries: an aid to management. J Bone Joint Surg [Br] 1985;67-B:53-7.
84. Ovre S, Hvaal K, Holm I, Stromsoe K, Nordsletten L, Skjeldal S. Compartment
pressure in nailed tibial fractures: a threshold of 30 mmHg for decompression gives 29%
fasciotomies. Arch Orthop Trauma Surg 1998;118:29-31.
85. Al-Dadah OQ, Darrah C, Cooper A, Donell ST, Patel AD. Continuous
compartment pressure monitoring vs. clinical monitoring in tibial diaphyseal fractures.
Injury 2008;39:1204-9.
86. Harris IA, Kadir A, Donald G. Continuous compartment pressure monitoring for
tibia fractures: does it infuence outcome? J Trauma 2006;60:1330-5.
87. Matsen FA 3rd, Mayo KA, Sheridan GW, Krugmire RB Jr. Monitoring of
intramuscular pressure. Surgery 1976;79:702-9.
88. Whitesides TE Jr, Haney TC, Harada H, Holmes HE, Morimoto K. A simple
method for tissue pressure determination. Arch Surg 1975;110:1311-13.
89. Mubarak SJ, Hargens AR, Owen CA, Garetto LP, Akeson WH. The wick
catheter technique for measurement of intramuscular pressure: a new research and
clinical tool. J Bone Joint Surg [Am] 1976;58-A:1016-20.
90. Rorabeck CH, Castle GS, Hardie R, Logan J. Compartmental pressure
measurements: an experimental investigation using the slit catheter. J Trauma
1981;21:446-9.
91. Moed BR, Thorderson PK. Measurement of intracompartmental pressure: a
comparison of the slit catheter, side-ported needle, and simple needle. J Bone Joint Surg
[Am] 1993;75-A:231-5.
92. Shakespeare DT, Henderson NJ, Clough G. The slit catheter: a comparison with
the wick catheter in the measurement of compartment pressure. Injury 1982;13:404-8.
93. McDermott AG, Marble AE, Yabsley RH. Monitoring acute compartment
pressures with the S.T.I.C. catheter. Clin Orthop 1984;190:192-8.
94. Willy C, Gerngross H, Sterk J. Measurement of intracompartmental pressure
with use of a new electronic transducer-tipped catheter system. J Bone Joint Surg [Am]
1999;81-A:158-68.
95. Boody AR, Wongworawat MD. Accuracy in the measurement of compartment
pressures: a comparison of three commonly used devices. J Bone Joint Surg [Am]
2005;87-A:2415-22.
96. Collinge C, Kuper M. Comparison of three methods for measuring
intracompartmental pressure in injured limbs of trauma patients. J Orthop Trauma
2010;24:364-8.
97. Arbabi S, Brundage SI, Gentilello LM. Near-infrared spectroscopy: a potential
method for continuous, transcutaneous monitoring for compartmental syndrome in
critically injured patients. J Trauma 1999;47:829-33.
98. Gentilello LM, Sanzone A, Wang L, Liu PY, Robinson L. Near-infrared
spectroscopy versus compartment pressure for the diagnosis of lower extremity
compartmental syndrome using electromyography-determined measurements of
neuromuscular function. J Trauma 2001;51:1-8.
99. Shuler MS, Reisman WM, Kinsey TL, et al. Correlation between muscle
oxygenation and compartment pressures in acute compartment syndrome of the leg. J
Bone Joint Surg [Am] 2010;92-A:863-70.
100. Shuler MS, Reisman WM, Cole AL, Whitesides TE Jr, Moore TJ. Near-
infrared spectroscopy in acute compartment syndrome: case report. Injury 2011;42:1506-
8.
101. White TO, Howell GE, Will EM, Court-Brown CM, McQueen MM. Elevated
intramuscular compartment pressures do not infuence outcome after tibial fracture. J
Trauma 2003;55:1133-8.
102. Heckman MM, Whitesides TE Jr, Grewe SR, Rooks MD. Compartment
pressure in association with closed tibial fractures: the relationship between tissue
pressure, compartment, and the distance from the site of the fracture. J Bone Joint Surg
[Am] 1994;76-A:1285-92.
103. Matava MJ, Whitesides TE Jr, Seiler JG 3rd, Hewan-Lowe K, Hutton WC.
Determination of the compartment pressure threshold of muscle ischemia in a canine
model. J Trauma 1994;37:50-8.
104. Mallo GC, Stanat SJ, Al-Humadi M, Divaris N. Posterior thigh compartment
syndrome as a result of a basketball injury. Orthopedics 2009;32:923.
105. Stockley I, Harvey IA, Getty CJ. Acute volar compartment syndrome of the
forearm secondary to fractures of the distal radius. Injury 1988;19:101-4.
106. Hwang RW, de Witte PB, Ring D. Compartment syndrome associated with distal
radial fracture and ipsilateral elbow injury. J Bone Joint Surg [Am] 2009;91-A:642-5.
107. Giannoudis PV, Tzioupis C, Pape HC. Early diagnosis of tibial compartment
syndrome: continuous pressure measurement or not? Injury 2009;40:341-2.
108. Hargens AR, Akeson WH, Mubarak SJ, et al. Fluid balance within the canine
anterolateral compartment and its relationship to compartment syndromes. J Bone Joint
Surg [Am] 1978;60-A:499-505.
109. Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure
THE JOURNAL OF BONE AND JOINT SURGERY
8 A. D. DUCKWORTH, M. M. MCQUEEN
measurements as a determinant for the need of fasciotomy. Clin Orthop 1975;113:43-51.
110. Heppenstall RB, Sapega AA, Scott R, et al. The compartment syndrome: an
experimental and clinical study of muscular energy metabolism using phosphorus nuclear
magnetic resonance spectroscopy. Clin Orthop 1988;226:138-55.
111. Heckman MM, Whitesides TE Jr, Grewe SR, et al. Histologic determination of
the ischemic threshold of muscle in the canine compartment syndrome model. J Orthop
Trauma 1993;7:199-210.
112. Brooker AF Jr, Pezeshki C. Tissue pressure to evaluate compartmental syndrome.
J Trauma 1979;19:689-91.
113. Mars M, Hadley GP. Raised compartmental pressure in children: a basis for
management. Injury 1998;29:183-5.
114. Hargens AR, Romine JS, Sipe JC, et al. Peripheral nerve-conduction block by
high muscle-compartment pressure. J Bone Joint Surg [Am] 1979;61-A:192-200.
115. Heppenstall RB, Sapega AA, Izant T, et al. Compartment syndrome: a
quantitative study of high-energy phosphorus compounds using 31P-magnetic resonance
spectroscopy. J Trauma 1989;29:1113-19.
116. Janzing HM, Broos PL. Routine monitoring of compartment pressure in patients
with tibial fractures: beware of overtreatment! Injury 2001;32:415-21.
117. Kakar S, Firoozabadi R, McKean J, Tornetta P 3rd. Diastolic blood pressure
in patients with tibia fractures under anaesthesia: implications for the diagnosis of
compartment syndrome. J Orthop Trauma 2007;21:99-103.
118. Styf JR, Crenshaw A, Hargens AR. Intramuscular pressures during exercise.
comparison of measurements with and without infusion. Acta Orthop Scand
1989;60:593-6.
119. Breit GA, Gross JH, Watenpaugh DE, Chance B, Hargens AR. Near-infrared
spectroscopy for monitoring of tissue oxygenation of exercising skeletal muscle in a
chronic compartment syndrome model. J Bone Joint Surg [Am] 1997;79-A:838-43.
120. Mohler LR, Styf JR, Pedowitz RA, Hargens AR, Gershuni DH. Intramuscular
deoxygenation during exercise in patients who have chronic anterior compartment
syndrome of the leg. J Bone Joint Surg [Am] 1997;79-A:844-9.