Management of Acute Compartment Syndrome

Publication Date: December 7, 2018
Last Updated: March 14, 2022

RECOMMENDATIONS

BIOMARKERS

A. Limited evidence supports that myoglobinuria and serum troponin level may assist in diagnosing acute compartment syndrome in patients with traumatic lower extremity injury. (L)
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B. Moderate evidence supports that, in patients with acute vascular ischemia, femoral vein lactate concentration sampled during surgical embolectomy may assist in the diagnosis of acute compartment syndrome. (M)
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C. Limited evidence supports that myoglobinuria does not assist in diagnosing acute compartment syndrome in patients with electrical injury. (L)
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SERUM BIOMARKERS IN LATE/MISSED ACS

In the absence of reliable evidence, it is the opinion of the work group that serum biomarkers do not provide useful information to guide decision making when considering fasciotomy for a presumed late-presentation or missed acute compartment syndrome. (C)
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PRESSURE METHODS

A. Moderate evidence supports that intracompartmental pressure monitoring assists in diagnosing acute compartment syndrome. (M)
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B. Moderate evidence supports the use of repeated/continuous intracompartmental pressure monitoring and a threshold of diastolic blood pressure minus intracompartmental pressure >30 mmHg to assist in ruling out acute compartment syndrome. (M)
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PRESSURE MONITORING IN LATE/MISSED ACS

In the absence of reliable evidence, it is the opinion of the work group 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. (C)
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PHYSICAL EXAM (AWAKE)

Limited evidence supports using serial clinical exam findings to assist in ruling in acute compartment syndrome. (L)
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PHYSICAL EXAM (OBTUNDED)

In the absence of reliable evidence, it is the opinion of the work group that without a dependable clinical examination (e.g. in the obtunded patient), repeated or continuous intracompartmental pressure measurements are recommended until acute compartment syndrome is diagnosed or ruled out. (C)
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ALTERNATIVE METHODS OF DIAGNOSIS

In the absence of reliable evidence, it is the opinion of the work group that there are no reported diagnostic modalities, other than direct pressure monitoring or clinical exam findings, that provide useful information to guide decision making when considering fasciotomy for acute compartment syndrome. (C)
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FASCIOTOMY METHODS

In the absence of reliable evidence, it is the opinion of the work group that fasciotomy technique (e.g. one vs two incision, placement of incisions) is less important than achieving complete decompression of the compartments of the affected extremity. (C)
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FASCIOTOMY FOR LATE/MISSED ACS

In the absence of reliable evidence, it is the opinion of the work group that performing fasciotomy is not indicated in an adult patient with evidence of irreversible intracompartmental (neuromuscular/vascular) damage. Fracture stabilization, if warranted in these patients, should utilize a technique (external fixation/casting) that does not violate the compartment. (C)
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ASSOCIATED FRACTURE

In the absence of reliable evidence, it is the opinion of the work group that operative fixation (external or internal) should be performed for initial stabilization of long bone fractures with concomitant acute compartment syndrome requiring fasciotomy. (C)
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WOUND MANAGEMENT

Limited evidence supports use of negative pressure wound therapy for management of fasciotomy wounds with regard to reducing time to wound closure and reducing need for skin grafting. (L)
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PAIN MANAGEMENT EFFECTS ON DIAGNOSIS

In the absence of reliable evidence, it is the opinion of the work group that neuraxial anesthesia may complicate the clinical diagnosis of acute compartment syndrome. If neuraxial anesthesia is administered, frequent physical examination and/or pressure monitoring should be performed. (C)
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Recommendation Grading

Overview

Title

Management of Acute Compartment Syndrome

Authoring Organization

American Academy of Orthopaedic Surgeons

Endorsing Organization

American Orthopaedic Foot and Ankle Society

Publication Month/Year

December 7, 2018

Last Updated Month/Year

January 29, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Operating and recovery room, Outpatient

Intended Users

Physical therapist, occupational therapist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Rehabilitation, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D003161 - Compartment Syndromes

Keywords

acute compartment syndrome (ACS)

Supplemental Methodology Resources

Data Supplement