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The Pathophysiology, Diagnosis and Current Management of Acute Compartment Syndrome

Many authors advocate the use of intra-compartmental pressure monitoring in all at risk patients and those where extra clinical vigilance is advised. It has also been suggested that pressure monitoring may detect acute compartment syndrome prior to the onset of clinical signs, in addition to reducing the time to fasciotomy and the development of subsequent sequelae’, while maintaining the rate of fasciotomy or any associated complications.

Abstract
Acute compartment syndrome (ACS) is a clinical diagnosis; the most determinant of outcome is early recognition and expeditious surgical intervention. ACS is otherwise known as a surgical emergency and a high level of suspicion is needed in all potential cases.

Brief Case Description
This study emphasizes the importance of time to diagnosis. Rorabeck concluded ‘almost complete recovery of limb function if fasciotomy was performed within six hours’. When fasciotomy was performed within twelve hours normal limb function was regained in only 68% of patients; after twelve hours only 8% regained normal function. With a late diagnosis of compartment syndrome, irreversible tissue ischemia develops causing potentially disastrous neurological deficits, muscle necrosis, ischemic contracture, infection, chronic pain, delayed fracture union, rhabdomyolysis, amputation and even death can occur.
Whitesides et al. introduced the concept that the threshold at which irreversible damage was done is variable and dependent on the perfusion pressure. The pressure difference, otherwise known as the “delta pressure” is the diastolic blood pressure minus the intra-compartmental pressure. (McQueen and Court-Brown)

Intervention and Outcome Summary
Compartment pressure monitoring using a STIC pressure monitor can aid in the diagnosis of compartment syndrome with a delta pressure of 30 mmHg or below suggestive of acute compartment syndrome. The definitive, or recommended, treatment is prompt surgical decompression of all the involved compartments. Time to diagnosis is critical. A delay of more than 6 hours is associated with irreversible myoneural damage. Delayed fasciotomy after 8-10 hours is associated with significantly increased risk which may outweigh any potential benefit.

 

Original Publication:
The Open Orthopaedics Journal
Authors:
James Donaldson, Behrooz Haddad, and Wasim S Khan