This critical analysis review by Duckworth and McQueen evaluates how acute compartment syndrome should be diagnosed. It compares the diagnostic performance of clinical signs against continuous intracompartmental pressure monitoring, defines the optimal pressure threshold for fasciotomy, and identifies which patients are at highest risk.
When a patient with a tibial fracture is young, male, or has a closed lower-energy injury, your index of suspicion for ACS must be high — these are the patients most likely to develop it and least likely to be recognized on clinical exam alone.
Do not rely on clinical signs to rule ACS in or out. A reassuring neurological exam, the absence of pain out of proportion, or present distal pulses do not exclude the diagnosis. Regional anesthesia and patient-controlled analgesia actively mask the most sensitive clinical indicators.
The standard of care supported by this paper is continuous ICP monitoring with a slit catheter, using the Edinburgh protocol: ΔP (diastolic BP minus ICP) ≤30 mmHg for more than 2 hours is the threshold to proceed to fasciotomy. Do not act on a single pressure reading. A one-time ΔP ≤30 mmHg carries a 35% false-positive rate.
When you see paralysis, irreversible injury has almost certainly already occurred. Only 13% of patients with pre-fasciotomy paralysis fully recover. The entire point of pressure monitoring is to fasciotomize before the compartment reaches that stage.
This critical analysis review by Duckworth and McQueen evaluates how acute compartment syndrome should be diagnosed. It compares the diagnostic performance of clinical signs against continuous intracompartmental pressure monitoring, defines the optimal pressure threshold for fasciotomy, and identifies which patients are at highest risk.
When a patient with a tibial fracture is young, male, or has a closed lower-energy injury, your index of suspicion for ACS must be high — these are the patients most likely to develop it and least likely to be recognized on clinical exam alone.
Do not rely on clinical signs to rule ACS in or out. A reassuring neurological exam, the absence of pain out of proportion, or present distal pulses do not exclude the diagnosis. Regional anesthesia and patient-controlled analgesia actively mask the most sensitive clinical indicators.
The standard of care supported by this paper is continuous ICP monitoring with a slit catheter, using the Edinburgh protocol: ΔP (diastolic BP minus ICP) ≤30 mmHg for more than 2 hours is the threshold to proceed to fasciotomy. Do not act on a single pressure reading. A one-time ΔP ≤30 mmHg carries a 35% false-positive rate.
When you see paralysis, irreversible injury has almost certainly already occurred. Only 13% of patients with pre-fasciotomy paralysis fully recover. The entire point of pressure monitoring is to fasciotomize before the compartment reaches that stage.