Overview and Rationale
The American Academy of Orthopaedic Surgeons (AAOS), and the Major Extremity Trauma and Rehabilitation Consortium, with input from representatives from the Orthopaedic Trauma Association, the Society of Military Orthopaedic Surgeons, representatives from San Antonio Military Health System, and the U.S. Air Force Critical Care Air Transport Team, recently published their clinical practice guideline (CPG), Management of Acute Compartment Syndrome (ACS).1 This CPG was approved by the AAOS Board of Directors in December 2018 and has been officially endorsed by the American College of Surgeons and the American Orthopaedic Foot & Ankle Society. The purpose of this CPG is to diagnose and treat ACS based on current best evidence.
The true incidence of ACS is unknown as the treatment, fasciotomy, essentially is the surrogate for determining the diagnosis. Although the economic burden of ACS is unknown, these injuries can result in prolonged hospital stays and increased costs compared with those without compartment syndrome. Developing ACS results in persistently poorer function and quality of life,2 and there are substantial medicolegal implications in the diagnosis and treatment of compartment syndrome that affect patients, providers, and the healthcare system, alike.3 Combat casualties shoulder a significant burden of the condition, with 15% of combat limb injuries resulting in fasciotomy,4 but this cohort also showed a significant improvement in patient outcomes with greater focus on treating compartment syndrome. With appropriate education to treating surgeons and greater recognition of the potential diagnosis, US casualty mortality and need for revision surgery were decreased.5
Therefore, the Department of Defense partnered with the AAOS to develop an evidence-based, CPG to aid practitioners in the diagnosis and treatment of ACS.1 Furthermore, the CPG represents a call for continued research to allow for more accurate and reliable diagnostic methods and treatments with less morbidity. An exhaustive literature search was conducted, resulting initially in over 200 articles for full review. The articles were then graded for quality and aligned with the workgroup's patients, interventions, and outcomes of concern. The workgroup used the established AAOS CPG methods to generate eight consensus statements regarding the diagnosis and treatment of compartment syndrome. Because of the lack of high-quality evidence, only six recommendations to guide diagnosis and one regarding management were made.
In summary, to create the ACS CPG, over 3,600 abstracts and more than 480 full-text articles were reviewed to develop 15 recommendations supported by publications meeting stringent inclusion criteria. Each recommendation is based on a systematic review of the research-related topic which resulted in three recommendations classified as moderate, four as limited, and eight consensus statements. The strength of recommendation is assigned based on the quality of the supporting evidence (Figure 1).
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 study7 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.
Table 1 -
CPG Recommendations for the Use of Biomarkers (Serum or Urine) to Aid in the Diagnosis of ACS
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.
Table 2 -
CPG Recommendations for the Use of Intracompartmental Pressure Measurements to Aid in the Diagnosis of ACS
||Description of Level of Evidence
||Moderate evidence supports that ICP monitoring assists in diagnosing ACS.
|Serial ICP monitoring
||Moderate evidence supports the use of repeated/continuous ICP monitoring and a threshold of diastolic blood pressure minus ICP >30 mmHg to assist in ruling out ACS.
|ICP in late presentation ACS
||In the absence of reliable evidence, it is the opinion of the workgroup that compartment pressure monitoring does not provide useful information to guide decision making when considering fasciotomy for an adult patient with evidence of irreversible intracompartmental (neuromuscular/vascular) damage.
CS = acute compartment syndrome, CPG = clinical practice guideline, ICP = intracompartmental pressure
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.
Table 3 -
CPG Recommendations for the Utility of Physical Examination to Aid in the Diagnosis of ACS
||Description of Level of Evidence
||Limited evidence supports using serial clinical examination findings to assist in ruling in ACS.
|Obtunded or intoxicated patient
||In the absence of reliable evidence, it is the opinion of the workgroup that without a dependable clinical examination (eg, in the obtunded patient), repeated or continuous ICP measurements are recommended until ACS is diagnosed or ruled out.
CS = acute compartment syndrome, CPG = clinical practice guideline, ICP = intracompartmental pressure
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.
Table 4 -
CPG Recommendations for Alternative Methods to Aid in the Diagnosis of ACS
||Description of Level of Evidence
|Alternative diagnostic methods
||In the absence of reliable evidence, it is the opinion of the workgroup that there are no reported diagnostic modalities (eg, electromyography and infrared spectroscopy), other than direct pressure monitoring or clinical examination findings, that provide useful information to guide decision making when considering fasciotomy for ACS.
CS = acute compartment syndrome, CPG = clinical practice guideline
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.
Table 5 -
CPG Recommendations for the Management of Injuries With or at Risk for ACS
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.
The AAOS/Major Extremity Trauma and Rehabilitation Consortium Management of Acute Compartment Syndrome Clinical Practice Guideline are evidence-based recommendations summarized in Tables 1–5. Discussions of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/acsguideline (Figure 1). Readers are urged to consult the full guideline for the comprehensive evaluation of the available scientific studies. The recommendations were established using methods of evidence-based medicine that rigorously control for bias, enhance transparency, and promote reproducibility.
The Summary of Recommendations is not intended to stand alone. Medical care should be based on evidence, a physician's expert judgment, and the patient's circumstances, values, preferences, and rights. For treatment procedures to provide benefit, mutual collaboration with shared decision making between the patient and physician/allied healthcare provider is essential.
A strong recommendation means that the quality of the supporting evidence is high. A moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but the quality/applicability of the supporting evidence is not as strong. A limited recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm. A consensus recommendation means that expert opinion supports the guideline recommendation, although there is no available empirical evidence that meets the inclusion criteria of the guideline's systematic review.
References printed in bold type are those published within the past 5 years.
1. American Academy of Orthopaedic Surgeons. Management of Acute Compartment Syndrome. http://www.aaos.org/metrcdod
. Accessed Dec 7, 2018.
2. Giannoudis PV, Nicolopoulos C, Dinopoulos H, Ng A, Adedapo S, Kind P: The impact of lower leg compartment syndrome on health related quality of life. Injury 2002;33:117-121.
3. Bhattacharyya T, Vrahas MS: The medical-legal aspects of compartment syndrome. J Bone Joint Surg Am 2004;86:864-868.
4. Kragh JH, Wade CE, Baer DG, et al.: Fasciotomy rates in operations enduring freedom and Iraqi freedom: Association with injury severity and tourniquet use. J Orthop Trauma 2011;25:134-139.
5. Kragh JF, San Antonio J, Simmons JW, et al.: Compartment syndrome performance improvement project is associated with increased combat casualty survival. J Trauma Acute Care Surg 2013;74:259-263.
6. Sahni V, Garg D, Garg S, Agarwal SK, Singh NP: Unusual complications of heroin abuse: Transverse myelitis, rhabdomyolysis, compartment syndrome, and ARF. Clin Toxicol (Phila) 2008;46:153-155.
7. Alamshah SM, Jahanshahi A, Minaee H, et al.: Investigating correlation of lower extremity muscle compartment syndrome with muscle related serum enzyme tests: Is any reliable biomarker? Biomed Pharmacol J 2016;3:1183-1188.
8. Cancio LC, Jimenez-Reyna JF, Barillo DJ, Walker SC, McManus AT, Vaughan GM: One hundred ninety-five cases of high-voltage electric injury. J Burn Care Rehab 2005;4:331-340.
9. Mitas P, Vejrazka M, Hruby J, et al.: Prediction of compartment syndrome based on analysis of biochemical parameters. Ann Vasc Surg 2014;28:170-177.
10. Janzing HM, Broos PL: Routine monitoring of compartment pressure in patients with tibial fractures: Beware of overtreatment! Injury 2001;32:415-421.
11. Dickson KF, Sullivan MJ, Steinberg B, Myers L, Anderson ER, Harris M: Noninvasive measurement of compartment syndrome. Orthopedics 2003;26:1215-1218.
12. McQueen MM, Christie J, Court-Brown CM: Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br 1996;78:95-98.
13. McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM: The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. J Bone Joint Surg Am 2013;95:673-677.
14. 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;60:1091-1095.
15. Sangwan SS, Marya KM, Devgan A, Siwach RC, Kundu ZS, Gupta PK: Critical evaluation of compartment pressure measurement by saline manometer in peripheral hospital setup. Trop Doct 2003;33:100-103.
16. Li W, Ji L, Tao W: Effect of vacuum sealing drainage in osteofascial compartment syndrome. Int J Clin Exp Med 2015;8:16112-16116.
17. Krticka M, Ira D, Bilik A, Rotschein P, Svancara J: Fasciotomy closure using negative pressure wound therapy in lower leg compartment syndrome. Bratisl Lek Listy 2016;117:710-714.
18. Mittal N, Bohat R, Virk JS, Mittal P: Dermotaxis v/s loop suture technique for closure of fasciotomy wounds: A study of 50 cases. Strateg Trauma Limb Reconstr 2017;0:1-7.
19. Zannis J, Angobaldo J, Marks M, et al.: Comparison of fasciotomy wound closures using traditional dressing changes and the vacuum-assisted closure device. Ann Plast Surg 2009;62:407-409.