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Diagnosis of acute
compartment syndrome
Acute compartment syndrome (ACS) is defined by a critical
pressure increase within a confined 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 al17 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 longterm complications such as muscle necrosis, contractures,
neurological deficits, 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, softtissue 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
2011 British Editorial Society of Bone and Joint Surgery
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 significantly younger age than females.15,33,34 The most
frequently affected sites are the leg13,20,35,36 and forearm,16,37-39
although the arm,40-43 hand,43-45 gluteal region,32,46 thigh,24,47-50
foot51-55 and abdomen56 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 significantly 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 identified 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
significantly older than those associated with a fracture.23
A variety of causes has been identified 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 traffic 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
1
A. D. DUCKWORTH, M. M. MCQUEEN
% of cases
Fracture
Tibial diaphyseal fracture
Distal radius fracture
Diaphyseal forearm fracture
Femoral diaphyseal fracture
Tibial plateau fracture
36
9.8
7.9
3.0
3.0
Soft tissue
Soft-tissue injury
Crush syndrome
23.2
7.9
Sensitivity (%)
Specificity (%)
PPV (%)
NPV (%)
Pain
Pain on
passive stretch
Paraesthesia
Paresis
19
97
14
98
19
97
14
98
13
98
15
98
13
97
11
98
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
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/fluid 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
Good accuracy
Continuous monitoring
No issues with transducer level
Indirect measure
Invasive
Increased expense
Requires heparinised saline
Requires re-sterilisation
Increased expense
Validation undetermined for ACS
Variable reading with varying depth of soft tissues
A. D. DUCKWORTH, M. M. MCQUEEN
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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
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