|

The Diagnosis of Acute

Compartment Syndrome
A Critical Analysis Review

Andrew D. Duckworth, Abstract

BSc(Hons), MBChB, MSc,
FRCSEd(Tr&Orth), PhD
Margaret M. McQueen, MD,
FRCSEd(Orth)
Investigation performed at the
Edinburgh Orthopaedic Trauma
Unit, Royal Infirmary of Edinburgh,
Edinburgh, Scotland, United Kingdom
» Delay in the diagnosis of acute compartment syndrome can have
severe and potentially disastrous outcomes for the patient.
» Factors associated with a delayed diagnosis are lack of experience of
medical personnel, regional or general anesthesia, polytrauma cases,
injuries to the soft tissue, and the use of clinical signs alone when
making the diagnosis.
» Youth has been identified as the key risk factor associated with
confirmed cases of acute compartment syndrome, and over two-thirds
of cases are associated with an underlying fracture.
» Although pain is characteristically the index sign associated with the
development of acute compartment syndrome, clinical findings in
isolation have been proven to have inadequate diagnostic perfor-
mance characteristics, with sensitivity ranging from 13% to 54%.

» Intracompartmental pressure monitoring is recommended for

patients at risk, given the documented high estimated sensitivity (94%)
and specificity (98%) for the diagnosis of acute compartment
syndrome when using a slit catheter technique and a differential
pressure threshold of 30 mmHg for .2 hours.

A
cute compartment syndrome
occurs within a confined
muscle compartment once
there is a critical pressure rise
to a level that decreases the blood supply
and perfusion pressure to the soft tissues
within the compartment1-6. Without ur-
gent fasciotomy and decompression of the
affected compartments6-9, tissue ischemia
and necrosis will lead to permanent func-
tional disability10-13. Ischemic contracture
is the end stage of acute compartment
syndrome and irreversible muscle necrosis
and was first described by Volkmann14.
The detrimental effects of a delayed
diagnosis and treatment of acute compart-
ment syndrome have been known for over
40 years15 and have been shown to result in
long-term complications, poor patient-
reported outcomes10,13,16-18, increased
medical costs19, and an increased number
of indemnity settlements when compared
with the mean for all orthopaedic
surgery20,21. Documented complications
include infection, muscle necrosis and
contractures, permanent neurological in-
jury, chronic pain, nonunion of associated
fractures, and even amputation or
death6,10,16,17,22-25.
A delay in the time to diagnosis of
acute compartment syndrome has been
associated with inexperience, regional or
general anesthesia, polytrauma cases, in-
juries to the soft tissues, and a sole reliance
on the clinical symptoms and signs to make
the diagnosis of acute compartment

COPYRIGHT © 2017 BY THE Disclosure: No external funding source played any role in this review. The Disclosure of Potential
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 | The Diagnosis of Acute Compartment Syndrome

syndrome6,24,26-32. Despite this, many 30 years of age than women at 44 years of syndrome following a fracture of the
centers still utilize clinical symptoms age39-41. Youth has been found to be tibia43, particularly after high-energy
and signs alone for the diagnosis. One the most important risk factor for de- mechanisms such as a motor vehicle ac-
series from a level-1 trauma center found veloping acute compartment syndrome, cident44. The one caveat for youth as
that intracompartmental pressure mon- possibly because of the relatively high a risk factor is in the case of soft-tissue
itoring was employed as the primary muscle bulk in a fixed compartment injuries that lead to acute compartment
diagnostic instrument in 11.7% of 386 and thus a reduced capacity for swelling syndrome, in which the mean age is
fractures of the tibial diaphysis33. in these patients. Older patients often older than that of patients who develop
have reduced muscle bulk secondary to acute compartment syndrome following
Epidemiology sarcopenia, with an associated increased a fracture23.
Data on the epidemiology of acute perfusion pressure due to hypertension, Overall, two-thirds of acute com-
compartment syndrome are invaluable which could potentially explain the partment syndrome cases are secondary
for identifying high-risk patients who protective effects of increasing age. to fracture. Fractures of the tibial di-
benefit from increased clinical vigilance In a retrospective case series from aphysis make up one-third of all pre-
and intracompartmental pressure mon- the Edinburgh Orthopaedic Trauma sentations39, with a prevalence of acute
itoring, with the aim of decreasing the time Unit of 1,388 patients who sustained an compartment syndrome found to
to definitive diagnosis and fasciotomy acute tibial diaphyseal fracture and had range from 2.7% to 15%17,39,43-49.
(Table I). Areas of the body com- a rate of acute compartment syndrome Although initial studies suggested that
monly involved are the leg13,16,34,35 and of 11.5% (n 5 160), multivariate re- intramedullary tibial nailing could be
the forearm25,36-38, with much of the gression analysis revealed that age was associated with an increased rate of acute
current data on the diagnosis of acute the strongest factor associated with the compartment syndrome17,49-52, this has
compartment syndrome in relation to development of acute compartment since been disproved53,54, with large
fractures of the tibial diaphysis, which syndrome, with the highest prevalence studies in patients with a fracture of the
is the main focus of this review. being in the second and third decades, tibia suggesting that youth, male sex,
The incidence in the Western and with all other factors strongly con- and diaphyseal fractures are key risk
world is 3.1 per 100,000 population per founded by age42. This is supported by factors for developing acute compart-
year39, with men more frequently af- other studies that have found that the ment syndrome6,55. However, recent
fected at 7.3 per 100,000 than women at prevalence of acute compartment syn- data have indicated a high rate of acute
0.7 per 100,000, a ratio of 10 to 125,39. drome is 3 times greater in patients ,35 compartment syndrome following frac-
The mean patient age is approximately years of age39 and that adolescents have tures of the tibial plateau (12% com-
32 years, with men being younger at an increased rate of acute compartment pared with 3% for shaft fractures)56,
with the Schatzker VI fracture type be-
ing particularly high risk56,57. Other
fractures associated with developing
TABLE I The Risk Factors for the Development or Late Diagnosis
of Acute Compartment Syndrome acute compartment syndrome are fore-
arm diaphyseal fractures (prevalence,
Risk factors for developing acute compartment syndrome 3%) and fractures of the distal part of the
Age (youth) radius (prevalence, 0.25%). These data
Fracture of the tibia are consistent with acute compartment
High-energy femoral shaft fracture syndrome in children, with 76% of
High-energy fracture(s) of the forearm acute compartment syndrome cases be-
Clotting abnormalities (e.g., use of warfarin) ing secondary to fractures, predomi-
Polytrauma nantly of the tibial diaphysis, the
Increase in lactate or base deficit forearm, and the distal part of the
Transfusion radius58.
Risk factors for a delay in the diagnosis of acute compartment syndrome Although fracture is the most
Reliance on clinical signs alone common cause, it is key to appreciate
Children that almost a quarter of all cases follow an
Associated neurological injury isolated soft-tissue injury23,25,39, with
Reduced or altered consciousness level some cases having no clear history of the
Regional anesthesia preceding injury. Potential precipitating
Patient-controlled analgesia causes include crush syndrome, crush
Lack of experience of medical personnel injuries, a drug overdose, and anti-
coagulation medications (e.g., warfarin

2 DECEMBER 2017 · VOLUME 5, ISSUE 12 · e1


therapy)22,24,36,39,41,59-64. Factors asso-
ciated with acute compartment syn-
drome secondary to soft-tissue injury
include increasing age and medical co-
morbidities, as well as anticoagulation.
Despite the commonly held per-
ception that open fractures and high-
energy injuries are associated with a
diagnosis of acute compartment syn-
drome, the literature supports a high rate
of acute compartment syndrome follow-
ing closed low-energy fractures of the
tibial diaphysis39,46,48,65. High-energy
injuries such as during sports, a fall from a
height, and a motor vehicle accident ac-
count for ,50% of all acute compart-
ment syndrome cases secondary to a
fracture of the tibial diaphysis39, with
these modes of injury accounting for ap-
proximately 50% of tibial diaphyseal
fractures that do not develop acute com-
partment syndrome66. Similar findings in
the literature are found for closed fractures
compared with open fractures of the tibia,
with not only closed fractures but frac-
tures with a lower Gustilo and Anderson
grade more commonly associated with
acute compartment syndrome39. Both of
these findings are possibly due to auto-
decompression of the compartment
boundaries at the time of the injury. De-
spite this, the literature does support an
increased rate of acute compartment
syndrome following high-energy fractures
of the femur and the forearm, likely be-
cause of the higher rate of young men who
have these types of injuries25,39,62,67.
TABLE II Reported Diagnostic Performance Characteristics of Clinical Symptoms and Signs of Acute
Compartment Syndrome and Intracompartmental Pressure Monitoring
Symptom or Sign Sensitivity (%)
Pain28
Pain on passive stretch28
Paralysis and motor
changes28
Paresthesia and sensory
changes28
Swelling123
Intracompartmental
pressure monitoring122
DECEMBER 2017 · VOLUME 5, ISSUE 12 · e1
The Diagnosis of Acute Compartment Syndrome
Table I lists predisposing risk fac-
tors for the development of acute com-
partment syndrome and the late or
delayed diagnosis of acute compartment
syndrome. Key factors associated with a
diagnostic delay have already been
highlighted6,24,26-32. Kosir et al.
reported a rate of 20% for lower-limb
acute compartment syndrome in 45
critically injured patients and found that
a high lactate level, an increased base
deficit, and a requirement for transfu-
sion were associated with the develop-
ment of the condition68. A systematic
review on the use of regional anesthesia
or patient-controlled analgesia and acute
compartment syndrome found no clear
delay in the time to diagnosis, although
the literature was very limited in terms of
size and design and further data in this
area are clearly needed69.
Diagnosis
Clinical Symptoms and Signs
The symptoms and signs indicative of
acute compartment syndrome are
swelling, pain on passive stretch, pain
out of proportion to the injury, pares-
thesia, and paresis or paralysis (Table II).
Absent peripheral pulses, pallor, and
reduced capillary return are late clinical
signs of acute compartment syndrome
and will be associated with a vascular
injury requiring an angiogram or an
established acute compartment syn-
drome in which amputation may be in-
evitable6. Conversely, it is unsafe to rule
Positive Predictive
Specificity (%) Value (%)
19 97
19 97
13 97
13 98
54 76
94 98
|
out a diagnosis of acute compartment
syndrome on the basis of present distal
pulses.
Swelling
Palpable and visible swelling is an almost
universally seen sign with acute com-
partment syndrome but is highly sub-
jective. Assessment is routinely
inadequate because of cast immobiliza-
tion as well as the difficulty in assessing
deep compartments18,70. Although
sensitivity is higher than for other clini-
cal symptoms and signs (54%), the
specificity (76%) and negative predic-
tive value (63%) are far inferior.
Pain
Pain is a very common early sign of acute
compartment syndrome in the awake
and alert patient28. It is frequently severe
and out of proportion to the apparent
extent of the injury, with increasing an-
algesia requirements. However, pain is
very subjective, and in the literature,
there are documented scenarios of acute
compartment syndrome occurring in
the absence of pain71. Pain can be
influenced by psychosocial factors such
as anxiety72, is almost universal follow-
ing injury, is of variable intensity3,22, for
example, when it involves the deep
posterior compartment3,18, and could
be even nonexistent with an associated
nerve injury8,73. Assessment can be very
difficult in children or patients with
learning disabilities in whom agitation
Negative Predictive
Value (%)
14 98
14 98
11 98
15 98
70 63
93 99
3
 | The Diagnosis of Acute Compartment Syndrome
and analgesia requirements are impor-
tant to assess58 and cannot be performed
at all in the presence of regional anesthesia
or in the unconscious patient26,27,30.
This results in a very low sensitivity
(19%) despite a good specificity (97%),
which equates to a large percentage of
false negative or missed cases, although
with a small percentage of false positive
cases13,18,22,28,73. Pain on passive stretch
of the muscle compartment involved
has analogous diagnostic performance
characteristics, as the same confound-
ing factors listed above also apply
(Table II)28,71,73.
Paresthesia
Although some have suggested that
paresthesia or hypoesthesia could be the
optimal sign for diagnosing acute com-
partment syndrome70, it is now estab-
lished as a late sign16 with a very low
sensitivity at 13% despite very good
specificity at 98%28. This rate of false
negatives excludes paresthesia as an accu-
rate diagnostic indicator. Reduced or ab-
sent sensation could be associated with
nerve ischemia within the involved com-
partment or concomitant injury73,74.
Paralysis
Muscle paralysis within the affected
compartment is a very late sign of
established acute compartment syn-
drome in which irreversible injury to
the soft tissues has occurred. Paralysis
prior to fasciotomy is associated with
poor outcome in acute compartment
syndrome12,34,62,65,75,76, with one series
finding that only 13% of patients fully
recovered34. The literature also suggests
that it is the worst clinical symptom or
sign in terms of combined sensitivity and
specificity (Table II)28, probably as it
could be related to pain inhibition sec-
ondary to the injury, nerve injury, or
direct injury to the soft tissues77.
Diagnostic Performance
Characteristics
Although the literature is clear that
employing a combination of clinical
symptoms and signs raises the sensitivity
for diagnosing acute compartment
4 DECEMBER 2017
syndrome28, this is not practical. Ulmer
carried out a systematic review of 4 studies
(132 cases) to determine the diagnostic
performance characteristics of the 4
commonly quoted symptoms and signs
associated with acute compartment syn-
drome, including pain on passive stretch,
pain, paralysis, and paresthesia. He found
that the sensitivity of each of the 4
symptoms and signs was low and that all
were better at discounting rather than
corroborating the diagnosis. The pres-
ence of 1 positive sign resulted in a ,26%
probability that acute compartment
syndrome would be confirmed, but with
3 positive symptoms or signs, this rose to
93%. However, the final sign included
was paralysis, which is known to be a very
late sign of acute compartment syndrome
in which irreversible disability is almost
inevitable.
Intracompartmental
Pressure Monitoring
Noninvasive Techniques
Assessment of the intracompartmental
pressure has been done using modern
noninvasive techniques with undeniable
advantages and potential, but the use of
these methods has yet to be adequately
validated in the literature. Near-infrared
spectroscopy is a noninvasive assessment
utilizing a probe placed on the skin to
determine the oxygen saturation of the
tissue and has been found to correlate
well with the tissue pressure in both ex-
perimental studies78 and studies with
healthy human volunteers79. Ultra-
sound scanning detects waveforms sec-
ondary to fascial displacement by the
arterial pulse, leading to attempts to
correlate intracompartmental pressure
readings of .30 mm Hg with fascial
displacement in healthy volunteers. The
sensitivity of this technique is 77%, with
a specificity of 93%80. The primary
limitation of this technique is a probable
reduction in sensitivity in the patient
with hypotension.
Invasive Techniques
The advantages and disadvantages of
each invasive monitoring technique are
found in Table III81. One of the first
invasive measurement techniques used a
needle manometer11,82,83 placed within
the compartment and connected to a
column filled with a mixture of saline
solution and air84; a modified technique
used an infusion of saline solution into
the compartment82. The intra-
compartmental pressure is calculated
through the accompanying manometer.
This is a simple and inexpensive
method, but the tip can become blocked
and there is major concern that the
large volume infused could worsen or
induce an acute compartment syn-
drome. A modification of this is the wick
catheter70,85 in which there are pro-
truding fibrils from the bore of the
catheter85, which confer a high surface
area for intracompartmental pressure
assessment and reduce the risk of ob-
struction. Despite this, false low mea-
surements can happen if there is a
blockage secondary to a blood clot or
if an air bubble impedes the fluid col-
umn. Similar to the wick catheter tech-
nique, the slit catheter86-88 increases
the tip surface area for measurement by
using an axial cut at the catheter end86.
The patency of the slit catheter can be
tested once the catheter is in situ
through applying light pressure to the
compartment, which should result in an
immediate elevation of the intra-
compartmental pressure reading. Again,
false low readings are possible with
blockage. The literature suggests that the
slit catheter has superior accuracy to the
continuous infusion method87, with
comparable accuracy to the wick
catheter88.
The intracompartmental pressure
can also be assessed using a solid-state
transducer intracompartmental catheter
(STIC)89-91 that uses a pressure trans-
ducer located directly within the cathe-
ter lumen, with good correlations
reported when compared with the con-
ventional techniques90. This technique
is expensive, and an infusion is needed to
maintain patency and can be potentially
labor-intensive for staff, although more
modern designs bypass this problem
with a transducer that is not dependent
on a fluid column for patency91.
· VOLUME 5, ISSUE 12 · e1
 The Diagnosis of Acute Compartment Syndrome |

TABLE III Advantages and Disadvantages of Currently Available Intracompartmental Pressure Monitoring Techniques
Used in Diagnosing Acute Compartment Syndrome48,54,70,78,79,82,85-91,93,94,124-128*

Method Advantages Disadvantages

Needle manometer Simple technique, low cost
Wick catheter Good accuracy due to high surface area,
blockage of catheter uncommon,
continuous monitoring feasible
Transducer-tip intracompartmental Good accuracy, continuous monitoring
catheter feasible, transducer level not important
Slit catheter Good accuracy due to high surface area,
continuous monitoring feasible
Near-infrared spectroscopy Good accuracy and correlation, continuous
monitoring feasible, non-invasive technique
Accuracy limited with false positives and
negatives, invasive indirect measure,
continuous measurement not feasible,
needle tip may block, fluid infusion can
deteriorate clinical picture
Invasive indirect measure, blockage at air-
fluid junction possible, wick material
retention possible, transducer must be at the
catheter level
Increased costs, resterilization necessary
Invasive indirect measure, catheter may
block, air bubble can lead to false low
reading, transducer must be at catheter level
Increased costs, not yet clearly validated for
acute compartment syndrome,
measurement dependent on soft-tissue
depth

*Reprinted, with modification, with permission from: Duckworth AD, McQueen MM. Diagnosis of acute compartment syndrome, J Bone Joint Surg Br.
Focus On. 2012 Jan.

The Stryker ICP (intra-
compartmental pressure) monitor is
frequently used in North America for
intracompartmental pressure monitor-
ing, although the accuracy of the
device has been found to be limited in
a study analyzing interobserver varia-
bility in 4 above-the-knee cadaveric
lower-leg acute compartment syndrome
models92. Boody and Wongworawat
analyzed the diagnostic performance
characteristics of 3 intracompartmental
pressure monitoring apparatuses
(Whitesides apparatus, Stryker ICP
monitor, arterial line manometer)
using an in vitro ovine muscle model93.
The authors found that all 3 devices
demonstrated a sound correlation be-
tween the calculated and measured
intracompartmental pressures.
Collinge and Kuper assessed 26
patients with suspected acute compart-
ment syndrome (97 compartments) to
contrast the STIC technique with the
modified Whitesides needle and an
electronic transducer-tipped catheter94.
They found a correlation coefficient of
0.83 and determined that, despite the
techniques being similar in terms of
intracompartmental pressure readings,
reliability for intracompartmental
pressure monitoring in the trauma
setting was not established, particu-
larly when utilized for single-reading
intracompartmental pressure
measurements94.
Catheter Placement
Accurate placement within the affected
compartment is performed using a strict
aseptic technique95. Current data sug-
gest that when there is an underlying
associated fracture, the catheter or device
tip should lie within 5 cm of the level of
the fracture to obtain the peak measure
of the intracompartmental pressure
reading within the compartment6,96-98.
However, it has been argued that tip
placement at the fracture level results in
inaccurately raised intracompartmental
pressure readings because of the fracture
hematoma99. It is important that the
level of the transducer is secured at the
level of the compartment being mea-
sured because of changes in the reading
with height.
Although it will not detect an in-
creased intracompartmental pressure in
the other compartments, the anterior
compartment of the leg is primarily
advocated because of evidence sug-
gesting that it is the most commonly
involved compartment and is readily
accessible45,48. Some studies endorse
concomitant intracompartmental
pressure monitoring in the deep pos-
terior compartment because of the
chance of neglecting an isolated deep
acute compartment syndrome, al-
though this is difficult and cumber-
some for the patient18,96. Others
would advocate this when the
clinical picture is suggestive of the
deep compartment being involved.
As with the leg, monitoring the
anterior compartment of the thigh
is advised because of frequent
involvement24,62,63,100,101, with iso-
lated posterior thigh acute compart-
ment syndrome also reported in the
literature102. For cases of suspected
foot acute compartment syndrome,
intracompartmental pressure moni-
toring of the interosseous compart-
ments is recommended by some, as
well as the calcaneal compartment in
injuries to the hindfoot64,103,104.

DECEMBER 2017 · VOLUME 5, ISSUE 12 · e1 5

 | The Diagnosis of Acute Compartment Syndrome
For the upper limb, the forearm is
the most commonly involved site, and
volar compartment measurement is
recommended22,25,36,38,67,105,106,
with the suspected rare isolated dorsal
acute compartment syndrome
requiring measurement of the intra-
compartmental pressure in the exten-
sor compartment25. The anterior
compartment of the arm and the hand
interosseous compartments are also
recommended6,67,107,108.
Threshold for Decompression
There has been extensive deliberation
with regard to the critical pressure
threshold for diagnosing acute com-
partment syndrome and proceeding
to fasciotomy, with the debate
centered around using either the intra-
compartmental pressure alone or the
differential pressure or perfusion pres-
sure (ΔP). The literature suggests that
the normal resting intracompartmental
pressure in adult muscle is around
10 mm Hg109. The early literature in
this area recommended employing
an absolute intracompartmental pres-
sure threshold of 30 to 40 mm
Hg12,46,70,82,107,110,111. Conversely, it
was recognized that the individual tol-
erance to the absolute intra-
compartmental pressure varied widely
and appeared to be intrinsically associ-
ated with the systemic blood pressure or
perfusion pressure48,84,97,112,113.
Whitesides et al. initially high-
lighted the value of employing the dif-
ferential (delta) pressure (ΔP) that is
equal to diastolic pressure – intra-
compartmental pressure84, with subse-
quent literature suggesting a ΔP of 10 to
35 mm Hg to be diagnostic97,113,114.
Subsequently, good clinical and experi-
mental data advocating that a pressure
difference of #30 mm Hg should
be used as a safe threshold for
fasciotomy13,48,95,115. However, it is
suggested that the critical DP will likely
be increased in traumatized or ischemic
muscle.
This concept was analyzed in a
clinical study of 116 patients, of whom
92 were male and the mean age was 33
6 DECEMBER 2017
years, who had an acute fracture of the
tibial diaphysis48 and underwent im-
mediate continuous anterior compart-
ment intracompartmental pressure
monitoring, which continued for a
minimum of 24 hours. Using a ΔP of
#30 mm Hg for .2 hours as the dif-
ferential pressure threshold for pro-
ceeding to fasciotomy, 3 patients
underwent fasciotomy and there were
no unnecessary fasciotomies (overtreat-
ment), no missed cases of acute com-
partment syndrome, and no related
sequelae at a mean final follow-up of
15 months48.
The above protocol was validated
in the same center by White et al. in a
series of 101 patients with a tibial
diaphyseal fracture. Forty-one patients
with an absolute intracompartmental
pressure reading of .30 mm Hg for .6
hours continuously (with a normal ΔP
of .30 mm Hg) were compared with
60 cases in which there was an absolute
intracompartmental pressure reading of
,30 mm Hg throughout. In the fol-
lowing 1-year period, there was no sig-
nificant difference in isometric muscle
analysis or in the return to function95.
There are a lack of data on the de-
compression threshold, both for other
regions (e.g., forearm) and for children.
In children, given the lower diastolic
pressure in this group, the mean arterial
pressure could be preferred when cal-
culating the ΔP116.
Timing
It is necessary to contemplate the trend
and timing of intracompartmental
pressure readings when assessing for a
diagnosis of acute compartment syn-
drome and the decision to proceed to
fasciotomy, particularly given that time
to fasciotomy is well established to be
associated with patient outcome10,13,16-18.
Experimental and clinical data suggest
that timing is of critical importance in
the development of muscle ischemia and
necrosis, which is dependent on the
clinical setting110,111,117,118. However,
a key limitation of the literature is the
definition of the time of onset of acute
compartment syndrome and therefore
the time to fasciotomy. In the acute
setting, it is suggested that the duration
of time to fasciotomy is best defined as
the point from admission as this is most
consistently defined6,23,48. Crush syn-
drome is the 1 exception to this, as the
inevitable long period of compression
makes it almost impossible to determine
the time of onset.
A variety of intracompartmental
pressure monitoring protocols were
tested in a prospective series of 95 pa-
tients with a fracture of the tibial di-
aphysis reviewed for a minimum of
1 year. Every patient underwent con-
tinuous intracompartmental pressure
monitoring, resulting in a 14.4%
fasciotomy rate119. When assessing the
diagnostic performance characteristics
reported, the best combined sensitivity
and specificity were clinical symptoms
accompanied by a ΔP of ,30 mm Hg
(61% sensitivity and 97% specificity),
with a ΔP of #30 mm Hg best
performing when using intra-
compartmental pressure monitoring
in isolation (89% sensitivity and 65%
specificity). The authors concluded
that an increased rate of fasciotomy
could occur with continuous intra-
compartmental pressure monitoring119.
However, the limitation of that study
was that it did not truly take into account
the trend of the ΔP over time.
Kakar et al. analyzed a prospective
cohort series of 242 fractures of the
tibial diaphysis that were managed with
intramedullary nailing under general
anesthesia and reported that although
the preoperative diastolic blood pressure
was associated with the postoperative
pressure, a significant difference (p ,
0.05) was found between the preopera-
tive pressure and the intraoperative pres-
sure (mean difference, 18 mm Hg)120.
This study highlights the importance of
using serial measurements when making
the decision to proceed to fasciotomy
and that intraoperative and immediate
postoperative readings should be inter-
preted with caution.
This evidence suggests that the de-
cision to proceed to fasciotomy cannot be
founded on a single intracompartmental
· VOLUME 5, ISSUE 12 · e1

pressure measurement except in severe or
extreme cases, as this will likely lead to an
increased rate of overtreatment and un-
necessary fasciotomies. Whitney et al.
reported a false positive rate of 35% if a
one-time ΔP reading of #30 mm Hg is
used without considering the trend over
time121. The Edinburgh protocol, which
involves employing a ΔP of #30 mm
Hg over a 2-hour period as the indication
for proceeding to urgent fasciotomy, is
well documented in the literature, with
results suggesting a reduction in the du-
ration of time to fasciotomy and the
complication rate, while not significantly
raising the rate of fasciotomy48. The
trend of the differential pressure should
be considered. If the DP is ,30 mm Hg
but the intracompartmental pressure is
decreasing and thus the DP is increasing,
then it is likely safe to observe the patient
closely in the expectation of the DP
returning to safe levels within a short
period of time.
Diagnostic Performance
Characteristics
The diagnostic performance character-
istics of continuous invasive intra-
compartmental pressure monitoring
have been reported in a series of 850
adult patients with an acute tibial di-
aphyseal fracture122. When employing
a technique in which a slit catheter is
inserted into the anterior compartment
of the leg and utilizing a diagnostic cri-
terion of a pressure differential (DP)
threshold of ,30 mm Hg for .2 hours,
the authors reported a sensitivity of
94% and a specificity of 98.4%, with
11 false positive and 9 false negative
cases. The positive predictive value was
reported as 93% and the negative pre-
dictive value was found to be 99%
(Table II). It should be noted that to
attain comparable results when using
symptoms and signs alone, 3 signs are
needed, with the third sign being paresis
that is indicative of irreversible injury to
the patient28. In a routine, day-to-day
clinical practice, the patient and the
treating surgeon need to acknowledge a
very small level of risk, although with
acute compartment syndrome, that risk
DECEMBER 2017 · VOLUME 5, ISSUE 12 · e1
The Diagnosis of Acute Compartment Syndrome |
inevitably needs to be balanced some- difficult to consistently perform in nor-
what in favor of the unnecessary fasci- mal clinical practice.
otomy (false positive). This is likely Harris et al. performed a prospec-
preferable to the issue of missing acute tive randomized trial involving 200
compartment syndrome (false consecutive tibial diaphyseal fractures
negative)122. comparing clinical assessment alone
(100 patients) and intracompartmental
Clinical Signs Compared pressure monitoring (100 patients),
with Intracompartmental with 5 patients developing acute com-
Pressure Monitoring partment syndrome (all in the clinical
In an analysis of 218 patients, Al-Dadah assessment group)99. The primary out-
et al. compared 109 consecutive patients come for this series was the late sequelae
with tibial diaphyseal fractures who of acute compartment syndrome at 6
had continuous intracompartmental months following injury. Noted com-
pressure monitoring with the control plications at the time of the final follow-
group, 109 historical patients who were up were sensory loss, contracture, toe
evaluated for acute compartment clawing, muscle weakness, and non-
syndrome with clinical signs alone45. union. There was no significant difference
Despite comparable fasciotomy rates in the complication rate (27% compared
(15.6% in the continuous intra- with 29%). A study limitation associ-
compartmental pressure monitoring ated with the indication to proceed to
group compared with 14.7% in the fasciotomy was the use of clinical
control group), no significant difference symptoms and signs, with monitoring
was reported in either outcome or time employed at the discretion of the phy-
to fasciotomy45. A study limitation sician99. For intracompartmental pres-
was the fact that the control group had sure monitoring to be robustly
clinical assessment performed on an compared without bias to clinical as-
hourly basis, which many would argue is sessment alone, the differential pressure
TABLE IV Grades of Recommendation for the Diagnosis of
Acute Compartment Syndrome
Recommendation Grade*
Youth is the most important risk factor B
associated with the development of acute
compartment syndrome, and over two-
thirds of cases are associated with an
underlying fracture.
Clinical symptoms and signs alone are B
inadequate in the diagnosis of acute
compartment syndrome because of well-
documented poor sensitivity.
All patients at risk of acute compartment B
syndrome should undergo continuous
intracompartmental pressure monitoring.
Decompression fasciotomy should be B
carried out primarily based on a differential
pressure of ,30 mm Hg for .2 hours.
*Grade A: Good evidence (Level-I studies with consistent findings) for or against
recommending intervention. Grade B: Fair evidence (Level-II or III studies with
consistent findings) for or against recommending intervention. Grade C: Con-
flicting or poor-quality evidence (Level-IV or V studies) not allowing a recom-
mendation for or against intervention. Grade I: There is insufficient evidence to
make a recommendation.
7
 | The Diagnosis of Acute Compartment Syndrome
over time needs to be the primary indi-
cation to proceed to fasciotomy.
McQueen et al. reviewed 25 pa-
tients with a tibial diaphyseal fracture that
was complicated by acute compartment
syndrome13, with 13 patients who had
undergone intracompartmental pressure
monitoring compared with 12 patients
who underwent only clinical assessment.
A significant difference in the time from
presentation to fasciotomy was found in
the cohort with clinical assessment alone
(16-hour difference; p , 0.05), with a
significantly higher rate of late acute
compartment syndrome sequelae (91%
for patients who underwent only clinical
assessment compared with 0% for pa-
tients who had undergone intra-
compartmental pressure monitoring;
p , 0.01) and a delay to union (8-week
delay; p , 0.05)13.
Conclusions
A summary of the graded evidence-
based recommendations for the diag-
nosis of acute compartment syndrome
is found in Table IV. It is well established
that expedient diagnosis and subsequent
management of acute compartment
syndrome gives the best outcome for the
patient. Given the evidence demon-
strating the superior diagnostic perfor-
mance characteristics of continuous
intracompartmental pressure monitor-
ing when compared with clinical signs
and symptoms alone, we believe that
continuous intracompartmental pres-
sure monitoring should be employed as a
diagnostic adjunct in all patients defined
as being at risk of acute compartment
syndrome. Youth is the key risk factor
for developing acute compartment syn-
drome, with tibial diaphyseal fractures
being the most common precipitating
injury. Ultimately, if acute compart-
ment syndrome is suspected, intra-
compartmental pressure monitoring is
recommended.
To gain the complete advantage of
intracompartmental pressure monitor-
ing, the diagnosis should be made using
sequential DP readings rather than
waiting for the development of clinical
symptoms and signs suggestive of acute
8 DECEMBER 2017
compartment syndrome if they are not
present. The decision to perform an ur-
gent fasciotomy primarily using intra-
compartmental pressure monitoring and
the differential pressure (DP), with clini-
cal symptoms and signs being used as an
adjunct to diagnosis, appears to be the
optimal approach to take. The threshold
for fasciotomy is debated, but a DP that is
persistently ,30 mm Hg for .2 hours,
or that is declining, has been found to
prevent a delay in the diagnosis and to
reduce long-term complications.
It is important to address the lim-
itations of the current literature where
possible. One of the important issues
with regard to the current data on the
diagnosis of acute compartment syn-
drome is the lack of a gold-standard
reference for the diagnosis of acute
compartment syndrome, with the prev-
alence documented in the current data
being ,30%33,39,55. In such clinical
situations, routine statistical analysis is
not robust and other methods including
latent class analysis and use of the Bayes
theorem are necessary to accurately de-
termine the diagnostic performance
characteristics. Although the gold stan-
dard would be to perform sufficiently
powered prospective randomized con-
trolled trials of clinical signs compared
with continuous intracompartmental
pressure monitoring, there are impor-
tant issues of bias due to the inherent
modification of routine day-to-day
clinical practice for the trial leading to a
predictable improvement in the fre-
quency and robustness of clinical
assessment.
Current data would also be im-
proved by reports of prospective
intermediate-term to long-term outcome
data on the efficacy of intracompartmental
pressure monitoring, along with reports
on the diagnostic performance charac-
teristics of different intracompartmental
pressure monitoring protocols. Data on
acute compartment syndrome in adoles-
cents and in areas of the body other than
the leg are needed to allow us to determine
the indications and protocols for using
intracompartmental pressure
monitoring.
Andrew D. Duckworth, BSc(Hons),
MBChB, MSc, FRCSEd(Tr&Orth), PhD1,
Margaret M. McQueen, MD,
FRCSEd(Orth)1
1Edinburgh Orthopaedic Trauma Unit,
Royal Infirmary of Edinburgh,
Edinburgh, Scotland, United Kingdom
E-mail address for A.D. Duckworth: andrew.
duckworth@ed.ac.uk
ORCID iD for M.M. McQueen: 0000-
0002-4626-6598
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