Fig. 1 The appropriate use criteria provide guidance for when a diagnosis of compartment syndrome indicates fasciotomy (release of the compartment). Here, fasciotomy is performed in a patient with a dislocated knee. An external fixator is used to stabilize the knee; the open wound shows the surgical release of the compartments.
REPRODUCED FROM SCHENCK RC, HUNTER RE, OSTRUM RF, ET AL: KNEE DISLOCATIONS. INSTR COURSE LECT 1999;48:515-22.

AAOS Now

Published 11/1/2019
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Terry Stanton

Academy Releases New Appropriate Use Criteria and Tool for Acute Compartment Syndrome

Following approval by the Board of Directors in September, the Academy has released appropriate use criteria (AUC) and a corresponding online tool for the Diagnosis and Management of Acute Compartment Syndrome (ACS).

The highly focused AUC—including just three sets of Indication Profiles and 27 total possible treatment scenarios—are designed to guide orthopaedic surgeons who encounter ACS infrequently. The tool can help surgeons recognize this potentially devastating condition and respond with appropriate and timely treatment when indicated.

“There are not very many situations in orthopaedics that are considered emergencies, but compartment syndrome is a true emergency,” said Julie Balch Samora, MD, PhD, MPH, who served as voting panel moderator (along with David Jevsevar, MD, MBA). “The danger in missing compartment syndrome is loss of function or loss of the limb itself, so this is an important, specific topic to address. This AUC is narrow in its focus by design, and the target audience is orthopaedic surgeons outside of academic traumatology and the Level 1 trauma center setting.” 

As with other AAOS AUCs, this resource provides clinicians with an algorithm-style tool for choosing management pathways based on the patient’s presenting indications, as entered by the physician. The treatment scenarios provided by AUC arise from recommendations in clinical practice guidelines (CPGs), in this case the CPG that was issued by the Academy in December 2018 as a collaborative effort with military and civilian surgeon members of the Major Extremity Trauma and Rehabilitation Consortium.

“A particular challenge in constructing this particular CPG is the fact that there are few standard diagnostic criteria for ACS,” the guideline development group noted in its introduction to the CPG document. “Surgeons diagnose compartment syndrome using their clinical judgment and/or results of objective measurements (such as compartment pressure), and once the diagnosis is made, emergent fasciotomy is performed, if diagnosed acutely.”

The three patient indication profiles, with three variables for each that the clinician selects and chooses, are:

Clinical signs and symptoms (e.g., pain, paresthesia, pain with passive stretch, and paresis [motor symptoms]):

  1. no applicable symptoms
  2. symptoms compatible with ACS
  3. symptoms unreliable (unknown/
    unreliable/obtunded)

Perfusion pressure (delta P = diastolic blood pressure – intracompartmental pressure):

  1. delta P < 30 mmHg (compromised perfusion)
  2. delta P > 30 mmHg (adequate perfusion)
  3. pressure not obtained

Biomarkers/labs (myoglobinuria, elevated serum creatinine or creatine phosphokinase):

  1. abnormal biomarkers
  2. normal biomarkers
  3. unknown biomarkers

The possible treatment options that the AUC will recommend according to the patient variables entered by the clinician are:

  1. fasciotomy
  2. consider alternate diagnosis
  3. frequent/serial observation
  4. obtain/repeat serum biomarker
  5. obtain/repeat pressure measurements

In selecting from the first category of clinical symptoms, the clinician should be mindful that a primary sign of compartment syndrome is pain out of proportion to the injury, particularly with passive stretch. Repeated calls for increased medication overnight may indicate compartment syndrome; this is particularly true in children, according to Michael J. Weaver, MD, orthopaedic trauma chief at Brigham and Women’s Hospital.

Compartment syndrome also may occur rarely without pain, he explained. “The patient has a tibia fracture, it is nailed, and it seems fine; they are wiggling their toes in the morning,” Dr. Weaver posited. “But in the afternoon, they have a foot drop or can’t bring up their great toe. You have to think hard if there is something going on.”

Consensus is strong that perfusion pressure—specifically, the value of intracompartmental pressure subtracted from diastolic blood pressure—is a critical diagnostic indicator, and in any equivocal presentation, compartment pressure should be measured. On the AUC tool, when the button for delta P < 30 mmHg is selected under perfusion pressure, the procedure recommendation is for fasciotomy for all scenarios unless “no applicable symptoms” is selected under clinical symptoms.

“The delta P threshold of 30 [mmHg] is generally accepted as not controversial,” Dr. Samora commented. “It has been established in the literature, and most would agree on using it as the cutoff.”

ACS typically is associated with high-energy trauma but can be encountered with low-energy mechanisms of injury, electrocution, or vascular injury, as well as after ischemia/reperfusion events, such as prolonged limb compression in patients with altered mental status (such as a drug overdose or intoxication). Regardless of the etiology, an increase in compartment contents from edema or bleeding raises intracompartmental pressure. If the pathophysiologic process continues and intramuscular pressure becomes high enough, myoneural capillary blood flow ceases and compartment contents become ischemic. 

In its introductory statement to the AUC, the workgroup noted that the incidence of ACS “is difficult to ascertain because concrete diagnostic criteria are elusive, and most reports use the incidence of fasciotomy as a surrogate for compartment syndrome.” Among patients presenting with ACS in one report, the most common diagnoses were tibial diaphyseal fracture (36 percent of cases), soft-tissue injury (23 percent), distal radius fracture (10 percent), crush injury (8 percent), and diaphyseal radius/ulna fracture (8 percent). For specific injuries, the highest rates seem to be in medial knee fracture-dislocations (53 percent) and bicondylar tibial plateau fractures (18 percent).

The ACS resources are available on the OrthoGuidelines app or at http://www.orthoguidelines.org/go/auc.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.