The Dreaded Acute Compartment Syndrome

Authors: Brit Long, MD (@long_brit, Attending Emergency Physician, San Antonio, TX) and Michael Gottlieb, MD, RDMS (Attending Emergency Physician and Ultrasound Director, Rush Medical Center, Chicago, IL) // Edited by: Alex Koyfman, MD (@EMHighAK, Attending Emergency Physician, UTSW, Dallas, TX)

Case

A 24-year-old male presents with severe right lower leg pain after a motorcycle accident. He suffered right comminuted tibia and fibula fractures, but fortunately, his only other injuries were some extremity abrasions and road rash. He was recently splinted after evaluation by orthopedics, and the results of several CT’s are still pending. His right leg pain continues to increase despite multiple doses of hydromorphone IV and what appears to be a great reduction based on post-splinting films. What could be going on?

The Dreaded Compartment Syndrome…

A surgical emergency, acute compartment syndrome (ACS) is the result of excessive pressure within a fascial compartment, leading to decreased perfusion.1-3 Incidence varies but is close to 0.7-7.3 cases per 100,000 people.2 Failure to treat ACS can cause long-term neurovascular deficits, and ACS is associated with significant medicolegal risk.4 In fact, 23% of medicolegal cases are due to misdiagnosis, and 32% of cases are due to delay to definitive treatment.5

The Risks

ACS is most common in patients < 35 years of age.  These patients have increased risk of high-energy injuries, stronger fascia, and greater muscle bulk.  Males are 10x more likely to experience ACS compared to females.2,6 Elderly patients have reduced muscle mass and more commonly hypertension, which increases perfusion pressures.7ACS most commonly occurs within 24 hours of the injury, but it can be delayed for days.8 Fractures are the most common cause, especially tibia fractures (2-9% of tibial fractures result in ACS).2,6,9-12 An open fracture does not mean ACS cannot occur, as the small fascial tears from these injuries do not decompress the compartment.12-15  Keep in mind that a variety of risk factors are associated with ACS:

How does ACS occur?

Increased pressure within a fascial or osteofascial compartment results in ACS, due to either increased volume within a fixed compartment (edema, hematomas) or decreased size of the compartment (extrinsic compression from body positioning, tight casts, or wound dressings).5,16-18  The increased pressure initially harms microcirculatory perfusion, but as the pressure continues to build, lymphatic, capillary, and small venule flow decrease, followed by reduction in the venous and arterial flow, leading to tissue ischemia and necrosis.5,16,17  If not treated, ACS can lead to fibrous tissue degeneration, neurologic damage, contractures, and even amputation.5,6,16,17 A cycle of worsening vascular flow and further increases in intracompartmental pressures is common. Necrosis can occur rapidly, as up to 1/3 of cases have necrosis of muscle within 3 hours after injury.19  One study found that neurologic injury is reversible if fasciotomy was performed within 4 hours, but injury is irreversible if the fasciotomy was delayed to after 12 hours.20

What compartments are commonly affected?

In the lower extremity, ACS most commonly affects the anterior compartment.21,22  Concern for ACS within the proximal leg or thigh requires a check of the anterior compartment of the thigh (due to its more frequent involvement),4,16,23,24  but isolated posterior compartment involvement can occur.25  For ACS of the foot, the interosseous intracompartmental pressure should be measured, and for hindfoot injuries, the calcaneal compartment should be assessed.26-32  ACS is most common in the volar compartment of the forearm for the upper extremity, but isolated dorsal ACS can occur.29-33  Monitoring of the arm anterior compartment and interosseous compartments of the hand is recommended.29,34-36

How reliable is your history and exam?

In the patient with severe trauma, the ABC’s come first. The injured extremity can be assessed after the ABCs, but keep in mind the key risk factors (Table 1), as well as any change in symptoms. Findings are often subtle, and early findings may only be found in alert patients.2,3,7 Diagnosis is tough in patients with altered mentation, severe trauma, substance abuse, and patients at the extremes of age.15 Severe pain is the earliest symptom (often out of proportion to exam).9,37,38  Patients often describe severe, burning, deep pain and worse with passive stretching,3  but pain is subjective and has poor sensitivity.9 Later symptoms include paresthesias, sensory deficits, and focal motor deficits.9,16,17  Pain can resolve in later stages with necrosis.15  Exam can reveal pain with palpation, pain with passive stretch, a tense or firm compartment, swelling of the affected limb, focal motor or sensory deficits, or decreased pulse or capillary refill.9,16,17  Paralysis and lack of pulses are rare, and compartment firmness is not reliable.3,21  Swelling is common, but again, subjective.7  The key to diagnosis is clinical suspicion and repeat exams!14,18  Digital palpation of the compartment is unreliable, with 49% sensitivity and 79% specificity for ACS of the hand and 24% sensitivity and 55% specificity for ACS of the leg.39,40  Abnormal pulse oximetry suggests poor limb perfusion, but a normal reading does not rule out ACS.7,9,15

Overall, signs and symptoms can suggest the diagnosis, but they are not definitive.9,41  Combining factors is better. A combination of pain with rest, pain with passive stretch, paralysis, and paresthesias increases sensitivity to 93%.9 Keep in mind that using clinical signs or symptoms alone is not recommended. Delayed diagnosis results in poor outcomes including infection, muscle necrosis, rhabdomyolysis, renal failure, muscle contractures, neurologic injury, chronic pain, fracture, amputation, and death.18,23,30,31,41-49  Missed diagnosis is associated with clinician inexperience, patient sedation, polytrauma, soft tissue injury, and reliance on signs and symptoms alone.9,23,42,50-55

What testing is needed?  

Creatine kinase (CK), renal function, liver function, urinalysis, and urine myoglobin are recommended. CK > 1000 units/mL or myoglobinuria suggest ACS, and CK levels will continue to increase during the course of ACS.7,9,15,56  Rhabdomyolysis is present in > 40% of traumatic ACS cases.56-58  Renal injury can occur, usually due to rhabdomyolysis.7,9,15,56 X-rays of the affected extremity are usually obtained to look for fractures and other potential underlying causes.18,23,42

Once ACS is suspected, definitive diagnosis involves obtaining the intracompartmental pressure, which is most commonly assessed with direct, invasive monitoring.7,9,16,59  There are a variety of invasive methods for measuring pressures, including needle manometry, the wick catheter, the Whitesides method, and the solid-state transducer intracompartmental catheter (STC) device (Table 3).7,16,17,59  The most common method is an STC device such as the Stryker monitorTM, or using an arterial line transducer system.7,9,16,17 For more, see this video from EM:RAP on using the Stryker monitorTM and this EPMonthly article for a step-by-step guide. The Stryker monitorTM is accurate, with a sensitivity of 94% and specificity of 98%.38,60,61  However, the literature for use of STC monitors in trauma patients is limited.50,51,62 

Pearls for Obtaining Pressures

When obtaining intracompartmental pressures, place the catheter within 5 cm of the fracture level, with the transducer secured at the level of the measured compartment.42,63-65 Make sure to keep the catheter tip outside of the actual fracture site. If placed within the fracture, levels will be falsely high.7,66  Failure to place the transducer at the same height of the catheter tip will cause a falsely high or low, depending upon the position.42,63,65  If the first pressure is normal, but concern for ACS is present, a compartment recheck is needed, with another pressure assessment.7,9,16,17,42

There are several noninvasive techniques, but they need further study. Near-infrared spectroscopy assesses the oxygen saturation of tissues, which shows promise in healthy volunteers and correlates with intracompartmental pressures.7,67-69 Ultrasound can assess the arterial pulse waveform in the setting of increased intracompartmental pressure, with a sensitivity of 77% and specificity of 93% for correlation with intracompartmental pressures in healthy patients.70 Neither of these is ready for the sick trauma patient.

What are the keys to diagnosis and management?

The most important point is to consider ACS. Once you suspect ACS, consult orthopedic or general surgery, remove any constrictive dressings, and avoid a dependent position of the extremity (try your best to keep the extremity at the level of the heart).7,9,14  Removing external compressive devices alone can reduce pressures by 65-85%.16,17,71,72   Reducing a displaced fracture will decrease edema.16,17,42  Analgesia is needed, but regional blocks are not recommended (they can make monitoring based on symptoms challenging).50,73-76  If the patient is hypotensive, resuscitation is needed to restore circulating volume.7,9,16,17

What’s this about using intracompartmental pressure alone versus differential pressure (ΔP)?7,9,16,17.42  The normal resting pressure within muscle is close to 8-10 mm Hg in adults and 10-15 mm Hg in children.77-81  Previous recommendations used an absolute intracompartmental pressure of 30-40 mm Hg as a threshold for fasciotomy.16,17,59,77,82-84  The problem with using an absolute pressure is that patients can vary widely concerning intracompartmental pressures.7,9,15  Also, different compartments have different pressure thresholds.16,17  Take the hand: an intracompartmental pressure > 15-20 mm Hg in the hand is a relative indication for fasciotomy.7,38  The key is perfusion pressure, but this can also vary based on many factors (age, pre-existing hypertension, vascular disease).13,59,60,85-87  The differential pressure is the diastolic pressure minus the intracompartmental pressure.7,9,16,17  Studies suggest that differential pressures of <30 mm Hg are an indication for fasciotomy, though critical ΔP is probably higher in muscle undergoing trauma or ischemia.7,13,22,64,88-90

Another important point is that outcomes improve with rapid diagnosis and decompression. Rapid fasciotomy is correlated with improved outcomes, including muscle and nerve injury and death.7,19,20,22,46,90   Unfortunately, a motor deficit due to ACS rarely improves with fasciotomy.3,7,42,46

A dynamic relationship exists among blood pressure, intracompartmental pressure, and time of elevated pressures.3,7,9,16,17,90  Higher pressures result in severe damage over a short period of time, but lower pressures sustained for long periods of time can cause similar damage.3,7,16,17  Do you need multiple measurements? Some use repeat clinical assessments, while others recommend continuous monitoring with a catheter attached to an arterial transducer in patients for whom assessment is difficult.3,7,13,91-93  The issue with single compartment measurement is that this can result in overdiagnosis and overtreatment.3,7,38,42  Several different protocols can be used pressure measurement, with studies comparing continuous pressure monitoring with serial monitoring.3,7,38,42  For continuous compartment measurements, clinical symptoms in combination with ΔP (<30 mm Hg) results in a sensitivity of 61% and specificity of 97%, while using ΔP in isolation results in a sensitivity of 89% and specificity of 65%.3,7,93  Diagnosing on single measures can result in unnecessary fasciotomies, with a false positive rate approaching 35%.98  Monitoring pressures over 2 hours using ΔP < 30 mm Hg as diagnostic criterion for ACS displays a sensitivity of 94% and specificity of 98.4%.13,38,42   What should you do? We recommend using a single measurement for patients who you can obtain a reliable history and exam, with repeat assessment if the first is normal and clinical suspicion for ACS stills remains. If the patient cannot provide a reliable history and exam, use continuous monitoring over at least two hours or several repeat assessments.3,7,16,17  A ΔP < 20 mm Hg is a definitive indication for fasciotomy, with < 30 mm Hg a relative indication.3,7,13,88,89  Using ΔP may also help diagnose ACS in hypotensive trauma patients.7,9,13,38,42  Signs of ACS and absolute intracompartmental pressures > 30 mmHg also require fasciotomy.3,7,16,17  If elevated pressures have been present for > 3 days, a fasciotomy is unlikely to help, and in these cases, no decompression is advised. Instead it should be allowed to form scar tissue.3,7,9

 

As discussed, definitive therapy is fasciotomy.56,97,98  The affected extremity and the number of compartments affects the approach.97-99

Approaches for Fasciotomy

Hyperbaric oxygen (HBO) may assist in management. HBO causes hyperoxic vasoconstriction, which can decrease edema and improve oxygenation.100,101  Keep in mind that HBO should not delay fasciotomy.100,101 At this point, more research is needed concerning HBO in ACS.

Disposition

ACS requires emergent evaluation by a surgeon (preferably orthopedics) with transfer to the OR. If the patient is at risk for ACS or ACS is suspected, admission with monitoring is the best course of action.3,7,9

Key Points

– Compartment syndrome is a time-sensitive surgical emergency caused by increased pressure within a closed compartment.

– ACS is associated with a number of risk factors but occurs most frequently after a fracture or trauma to the involved area.

Pain out of proportion to the injury, paresthesias, pain with passive stretch, tense compartment, focal motor or sensory deficits, or decreased pulse or capillary refill time are signs and symptoms concerning for ACS.

Pain is the earliest finding in patients with ACS, but findings on history and exam cannot rule out the diagnosis.

Measurement of intracompartmental pressures using a pressure monitor is the most reliable test.

– Treatment involves analgesia, removing constrictive dressing, placing the limb at heart level, and surgical consultation for emergent fasciotomy.

From Dr. Katy Hanson at Hanson’s Anatomy:

References/Further Reading:

  1. Matsen FA 3rd, Krugmire RB Jr. Compartmental syndromes. Surg Gynecol Obstet. 1978 Dec;147(6):943-9.
  2. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000 Mar;82(2):200-3.
  3. Donaldson J, Haddad B, Khan WS. The pathophysiology, diagnosis and current management of acute compartment syndrome. Open Orthop J. 2014 Jun 27;8:185-93.
  4. Schwartz JT Jr, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am. 1989 Mar;71(3):392-400.
  5. Marchesi M, Marchesi A, Calori GM, et al. A sneaky surgical emergency: Acute compartment syndrome. Retrospective analysis of 66 closed claims, medico-legal pitfalls and damages evaluation. Injury. 2014 Dec;45 Suppl 6:S16-20.
  6. Lollo L, Grabinsky A. Clinical and functional outcomes of acute lower extremity compartment syndrome at a Major Trauma Hospital. Int J Crit Illn Inj Sci. 2016 Jul-Sep;6(3):133-142.
  7. Duckworth AD, McQueen MM. The Diagnosis of Acute Compartment Syndrome. JFJS Reviews 2017;5(12):e1.
  8. Ferlic PW, Singer G, Kraus T, Eberl R. The acute compartment syndrome following fractures of the lower leg in children. Injury. 2012 Oct;43(10):1743-6.
  9. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma. 2002 Sep;16(8):572-7.
  10. Erdös J, Dlaska C, Szatmary P, et al. Acute compartment syndrome in children: a case series in 24 patients and review of the literature. Int Orthop. 2011 Apr;35(4):569-75.
  11. Bodansky D, Doorgakant A, Alsousou J, et al. Acute Compartment Syndrome: Do guidelines for diagnosis and management make a difference? Injury. 2018 Apr 20. doi: 10.1016/j.injury.2018.04.020. [Epub ahead of print]
  12. Mauser N, Gissel H, Henderson C, et al. Acute lower-leg compartment syndrome. Orthopedics. 2013 Aug;36(8):619-24.
  13. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. 1996 Jan;78(1):99-104.
  14. Taylor RM, Sullivan MP, Mehta S. Acute compartment syndrome: obtaining diagnosis, providing treatment, and minimizing medicolegal risk. Curr Rev Musculoskelet Med. 2012 Sep;5(3):206-13.
  15. Via AG, Oliva F, Spoliti M, Maffulli N. Acute compartment syndrome. Muscles Ligaments Tendons J. 2015 Mar 27;5(1):18-22.
  16. Schmidt AH. Acute Compartment Syndrome. Orthop Clin North Am. 2016 Jul;47(3):517-25.
  17. Schmidt AH. Acute compartment syndrome. Injury. 2017 Jun;48 Suppl 1:S22-S25.
  18. Mabvuure NT, Malahias M, Hindocha S, et al. Acute compartment syndrome of the limbs: current concepts and management. Open Orthop J. 2012;6:535-43.
  19. Vaillancourt C, Shrier I, Vandal A, et al. Acute compartment syndrome: how long before muscle necrosis occurs? CJEM. 2004 May;6(3):147-54.
  20. Rorabeck CH, Clarke KM. The pathophysiology of the anterior tibial compartment syndrome: an experimental investigation. J Trauma. 1978 May;18(5):299-304.
  21. Al-Dadah OQ, Darrah C, Cooper A, et al. Continuous compartment pressure monitoring vs. clinical monitoring in tibial diaphyseal fractures. Injury. 2008 Oct;39(10):1204-9.
  22. McQueen MM, Christie J, Court-Brown CM. Acutecompartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br. 1996 Jan;78(1):95-8.
  23. Mithofer K, Lhowe DW, Vrahas MS, et al. Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries. Clin Orthop Relat Res. 2004 Aug;425:223-9.
  24. Mithoefer K, Lhowe DW, Vrahas MS, et al. Functionaloutcome after acute compartment syndromeof the thigh. J Bone Joint Surg Am. 2006 Apr;88(4):729-37.
  25. Mallo GC, Stanat SJ, Al-Humadi M, Divaris N. Posterior thigh compartmentsyndrome as a result of a basketball injury.Orthopedics. 2009 Dec;32(12):923.
  26. Frink M, Hildebrand F, Krettek C, et al. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010 Apr;468(4):940-50.
  27. Myerson M. Diagnosis and treatment of compartment syndrome of the foot. Orthopedics. 1990 Jul;13(7):711-7.
  28. Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin Orthop Relat Res. 1993 May;290:142-50.
  29. Tollens T, Janzing H, Broos P. The pathophysiology of the acute compartment syndrome. Acta Chir Belg 1998; 98: 171–75.
  30. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am. 2011 Mar;36(3):535-43.
  31. Eaton RG, Green WT. Volkmann’s ischemia. A volar compartment syndrome of the forearm. Clin Orthop Relat Res. 1975 Nov-Dec;113:58-64.
  32. Stockley I, Harvey IA, Getty CJ. Acute volar compartment syndrome of the forearm secondary to fractures of the distal radius. Injury. 1988 Mar;19(2):101-4.
  33. Hwang RW, de Witte PB, Ring D. Compartment syndrome associated with distalradial fracture and ipsilateral elbow injury. J Bone Joint Surg Am. 2009 Mar 1;91(3):642-5.
  34. Prasarn ML, Ouellette EA. Acute compartment syndrome of the upper extremity. J Am Acad Orthop Surg. 2011 Jan;19(1):49-58.
  35. Halpern AA, Greene R, Nichols T, Burton DS. Compartment syndrome of theinterosseous muscles: early recognition andtreatment. Clin Orthop Relat Res. 1979 May;140:23-5.
  36. Diminick M, Shapiro G, Cornell C. Acute compartment syndrome of the triceps and deltoid. J Orthop Trauma. 1999 Mar-Apr;13(3):225-7.
  37. Shadgan B, Pereira G, Menon M, et al. Risk factors for acute compartment syndrome of the leg associated with tibial diaphyseal fractures in adults. J Orthop Traumatol. 2015 Sep;16(3):185-92.
  38. 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 Apr 17;95(8):673-7.
  39. Wong JC, Vosbikian MM, Dwyer JM, Ilyas AM. Accuracy of measurement of hand compartment pressures: a cadaveric study. J Hand Surg Am. 2015 Apr;40(4):701-6.
  40. Shuler FD, Dietz MJ. Physicians’ ability to manually detect isolated elevations in leg intracompartmental pressure. J Bone Joint Surg Am. 2010 Feb;92(2):361-7.
  41. Gourgiotis S, Villias C, Germano S, et al. Acute limb compartment syndrome: a review. J Surg Educ. 2007 May-Jun;64(3):178-86.
  42. McQueen MM. Acute compartment syndrome. In: Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, III, editors. Rockwood and Green’s fractures in adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p 689-708.
  43. Gelberman RH, Zakaib GS, Mubarak SJ, et al. Decompression of forearm compartment syndromes. Clin Orthop Relat Res. 1978 Jul-Aug;134:225-9.
  44. Holden CE. The pathology and prevention of Volkmann’s ischaemic contracture. J Bone Joint Surg Br. 1979 Aug;61-B(3):296-300.
  45. Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome: course after delayed fasciotomy. J Trauma. 1996 Mar;40(3):342-4.
  46. Sheridan GW, Matsen FA 3rd. Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am. 1976 Jan;58 (1):112-5.
  47. Rorabeck CH, Macnab L. Anterior tibial-compartment syndrome complicating fractures of the shaft of the tibia. J Bone Joint Surg Am. 1976 Jun;58(4):549-50.
  48. Mullett H, Al-Abed K, Prasad CV, O’Sullivan M. Outcome of compartment syndrome following intramedullary nailing of tibial diaphyseal fractures. Injury. 2001 Jun;32(5): 411-3.
  49. Hope MJ, McQueen MM. Acute compartment syndrome in the absence of fracture. J Orthop Trauma. 2004 Apr;18(4): 220-4.
  50. Mubarak SJ, Wilton NC. Compartment syndromes and epidural analgesia. J Pediatr Orthop. 1997 May-Jun;17(3):282-4.
  51. Harrington P, Bunola J, Jennings AJ, Bush DJ, Smith RM. Acute compartment syndrome masked by intravenous morphine from a patient-controlled analgesia pump. Injury. 2000 Jun;31(5):387-9.
  52. Richards H, Langston A, Kulkarni R, Downes EM. Does patient controlled analgesia delay the diagnosis of compartment syndrome following intramedullary nailing of the tibia? Injury. 2004 Mar;35(3):296-8.
  53. Davis ET, Harris A, Keene D, et al. The use of regional anaesthesia in patients at risk of acute compartment syndrome. Injury. 2006 Feb;37(2):128-33. Epub 2005 Oct 26.
  54. Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009 Jan;102(1):3-11.
  55. Roberts CS, Gorczyca JT, Ring D, Pugh KJ. Diagnosis and treatment of less common compartment syndromes of the upper and lower extremities: current evidence and best practices. Instr Course Lect. 2011;60:43-50.
  56. Raza H, Mahapatra A. Acute Compartment Syndrome in Orthopedics: Causes, Diagnosis, and Management. Advances in Orthopedics 2015;1-8.
  57. Tsai WH, Hunag ST, Liu WC. High Risk of Rhabdomyolysis and Acute Kidney Injury After Traumatic Limb Compartment Syndrome. Ann Plast Surg 2015;74: S158–S161.
  58. Lima RS, da Silva Junior GB, Liborio AB et al. Acute kidney injury due to rhabdomyolysis. Saudi J Kidney Dis Transpl. 2008;19(5):721–9.
  59. Matsen FA 3rd, Winquist RA, Krugmire RB Jr. Diagnosis and management of compartmentalsyndromes. J Bone Joint Surg Am. 1980 Mar;62(2):286-91.
  60. Large TM, Agel J, Holtzman DJ, et al. Interobserver variability in the measurement of lower leg compartment pressures. J Orthop Trauma. 2015 Jul;29(7):316-21.
  61. Boody AR, Wongworawat MD. Accuracy in the measurement of compartment pressures: a comparison of three commonly used devices. J Bone Joint Surg Am. 2005 Nov;87(11):2415-22.
  62. Collinge C, Kuper M. Comparison of three methods for measuring intracompartmental pressure in injured limbs of trauma patients. J Orthop Trauma. 2010 Jun;24(6):364-8.
  63. Heckman MM, Whitesides TE Jr, Grewe SR, Rooks MD. Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the site of the fracture. J Bone Joint Surg Am. 1994 Sep;76(9):1285-92.
  64. Matava MJ, Whitesides TE Jr, Seiler JG 3rd, et al. Determination of the compartment pressure threshold of muscle ischemia in a canine model. J Trauma. 1994 Jul;37(1):50-8.
  65. Saikia KC, Bhattacharya TD, Agarwala V. Anterior compartment pressure measurementin closed fractures of leg. Indian J Orthop. 2008Apr;42(2):217-21.
  66. Harris IA, Kadir A, Donald G. Continuous compartment pressure monitoring for tibiafractures: does it influence outcome? J Trauma.2006 Jun;60(6):1330-5; discussion 1335.
  67. Garr JL,Gentilello LM, Cole PA, at al. Monitoring for compartmental syndromeusing near-infrared spectroscopy: a noninvasive, continuous,transcutaneous monitoring technique. Journal of Trauma—Injury, Infection and Critical Care. 1999;46(4):613–618.
  68. Arbabi S, Brundage SI, Gentilello LM. Near-infrared spectroscopy: a potential method for continuous, transcutaneous monitoring for compartmental syndrome in critically injured patients. J Trauma. 1999 Nov;47(5):829-33.
  69. Gentilello LM, Sanzone A, Wang L, et al. Near-infrared spectroscopy versus compartment pressure for the diagnosis of lower extremity compartmental syndrome using electromyography-determined measurements of neuromuscular function. J Trauma. 2001 Jul;51(1):1-8; discussion 8-9.
  70. Lynch JE, Lynch JK, Cole SL, et al. Noninvasive monitoring of elevated intramuscular pressure in a model compartment syndrome via quantitative fascial motion. J Orthop Res. 2009 Apr;27(4):489-94.
  71. Mars M, Hadley GP. Raised compartmental pressure in children: a basis for management. Injury. 1998;29:183-185.
  72. Hoover TJ, Siefert JA. Soft tissue complications of orthopaedic emergencies. Emerg Med Clin N Am. 2000;18:115.
  73. Cometa MA, Esch AT, Boezaart AP. Did continuous femoral and sciatic nerve block obscure the diagnosis or delay the treatment of acute lower leg compartment syndrome? A case report. Pain Med. 2011; 5: 823-828.
  74. Fowler SJ, Symons J, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve blockade after major knee surgery: A systematic review and meta-analysis of randomized trials. Br J Anaesth. 2008; 2: 154-164.
  75. Uzel AP, Steinmann G. Thigh compartment syndrome after intramedullary femoral nailing: Possible femoral nerve block influenceon diagnosis timing. Orthop Traumatol Surg Res. 2009; 4: 309-313.
  76. Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg (Br). 1996; 3: 499-500.
  77. Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint Surg Br. 1984 Jan;66(1):93-7.
  78. Giannoudis PV, Tzioupis C, Pape HC. Early diagnosis of tibial compartment syndrome: continuous pressure measurement or not? Injury. 2009 Apr;40(4):341-2.
  79. Shadgan B, Menon M, Sanders D, et al. Current thinking about acute compartment syndrome of the lower extremity. Can J Surg. 2010;53:329–34.
  80. Shadgan B, Menon M, O’Brien PJ, Reid WD. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma 2008; 22: 581–87.
  81. Staudt JM, Smeulders MJ, van der Horst CM. Normal compartment pressures of the lower leg in children. J Bone Joint Surg Br 2008;90: 215–19.
  82. Blick SS, Brumback RJ, Poka A, et al. Compartment syndrome in open tibial fractures. J Bone Joint Surg Am. 1986 Dec; 68(9):1348-53.
  83. Hargens AR, Akeson WH, Mubarak SJ,et al. Fluid balance within the canine anterolateral compartment and its relationship to compartment syndromes. J Bone Joint Surg Am. 1978 Jun;60(4):499-505.
  84. Allen MJ, Stirling AJ, Crawshaw CV, Barnes MR. Intracompartmental pressure monitoring of leg injuries. An aid to management. J Bone Joint Surg Br. 1985 Jan;67(1):53-7.
  85. Matsen FA 3rd, Veith RG. Compartmental syndromes in children. J Pediatr Orthop 1981; 1: 33–41.
  86. Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res 1975; Nov–Dec: 43–51.
  87. Heckman MM, Whitesides TE Jr, Grewe SR, et al. Histologic determination of the ischemic threshold of muscle in the canine compartment syndrome model. J Orthop Trauma. 1993;7(3):199-210.
  88. White TO, Howell GE, Will EM, et al. Elevated intramuscular compartment pressures do not influence outcome after tibial fracture. J Trauma. 2003 Dec;55(6):1133-8.
  89. Ozkayin N, Aktuglu K. Absolute compartment pressure versus differential pressure for the diagnosis of compartment syndrome in tibial fractures. Int Orthop. 2005 Dec;29(6):396-401.
  90. Matsen FA 3rd. Compartmental syndrome. An unified concept. Clin Orthop Relat Res. 1975 Nov-Dec. 8-14.
  91. Frink M, Klaus AK, Kuther G, et al. Long term results of compartment syndrome of the lower limb in polytraumatized patients. Injury 2007; 38: 607–13.
  92. Whitney A, O’Toole RV, Hui E, et al. Do one-timeintracompartmental pressure measurementshave a high false-positive rate in diagnosingcompartment syndrome? J Trauma Acute CareSurg. 2014 Feb;76(2):479-83.
  93. Janzing HM, Broos PL. Routine monitoring of compartment pressure in patients with tibial fractures: beware of overtreatment! Injury. 2001 Jun;32(5):415-21.
  94. Howard JL, Mohtadi NGH, Wiley JP. Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg. Clin J Sports Med. 2000;10:176-184.
  95. Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciotomy revision and delayed compartment release in combat patients. J Trauma. 2008; 2(Suppl): S153-61. discussion S161-2.
  96. Rollins DL, Bernhard VM, Towne JB. Fasciotomy: An appraisal of controversial issues. Arch Surg. 1981; 11: 1474-1481.
  97. PearseMF, Harry L, Nanchahal J. Acute compartment syndrome of the leg Fasciotomies must be performed early,butgood surgical technique is important. BMJ 2002;325(7364):557-8.
  98. Malik AA, Khan WS, Chaudhry A, Ihsan M, Cullen NP. Acute compartment syndrome–a life and limb threatening surgical emergency. J Perioper Pract 2009; 19(5): 137-42.
  99. Ojike NI, Roberts CS, Giannoudis PV. Compartment syndrome ofthe thigh: a systematic review. Injury 2010; 41(2): 133-6.
  100. Undersea and Hyperbaric Medical Society. June 2003. Indications for hyperbaric oxygen therapy. Available at http://www.uhms.org/Indications/indications.htm. Accessed: 17 May 2018.
  101. Wattel F, Mathieu D, Nevière R, Bocquillon N. Acute peripheral ischaemia and compartment syndromes: a role for hyperbaric oxygenation. Anaesthesia. 1998 May. 53 Suppl 2:63-5.

One thought on “The Dreaded Acute Compartment Syndrome”

Leave a Reply

Your email address will not be published. Required fields are marked *