Physical Exam (Awake)
Limited evidence supports using serial clinical exam findings to assist in ruling in acute compartment syndrome.
Management of Acute Compartment Syndrome
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: ACS, AOFAS, and SOMOS


One moderate quality study (Janzing, 2001) showed serial clinical testing (e.g. pain, pallor, pulse, swelling, etc.) to have a moderate association with the performance of fasciotomy for presumed ACS in patients with tibia fractures. Patients were examined and compartment pressures checked hourly for 6 hours then every 3 hours for at least 24 hours. ACS was defined as a patient indicated for fasciotomy or those who suffered a sequelae attributed to ACS, not a specific intracompartmental pressure or operative findings. This study also compared different thresholds for indicating patients for fasciotomy with clinical examination being specific (0.87) for surgery but less sensitive (0.67) than intracompartmental pressure monitoring. Pressure monitoring in symptomatic patients did obviate the need for fasciotomy in some cases, however the authors acknowledge the inability to truly diagnose ACS, using indicated fasciotomy as a surrogate for the diagnosis.

Two other low quality studies (Dickson, 2003; Mubarak, 1978) assessed clinical symptoms for the diagnosis of ACS, but they were deemed relevant only to the pressure testing recommendations (2a and 2b). Mubarak, et al utilized compartment pressure monitoring in patients who presented with clinical symptoms/signs of ACS. These clinical findings were used as the threshold to perform further intracompartmental testing instead of being compared to pressure values. Similarly, Dickson et al identified patients with pain and swelling for inclusion in studying a new device comparing limb hardness to intracompartmental pressure values.

The four included studies included patients without acute trauma and varying definitions for ACS, with dissimilar roles of clinical diagnosis for diagnosing ACS, thus the findings should be interpreted with caution.


Due to the difficulty in accurately diagnosing true compartment syndrome, reliance on clinical
examination may lead to both missed diagnosis and, conversely, overtreatment with “unnecessary”
fasciotomy. Many clinicians rely on exam findings and the suspicion of ACS should prompt further
investigation with serial exams or pressure measurement. Reliance on a single negative exam may result
in a missed diagnosis and dependence solely on classic symptoms may lead to overdiagnosis.


The unreliability of clinical examination further supports the need for research into noninvasive
compartment pressure/perfusion techniques as well as delineation of clear pressure values that indicate
the presence of ACS.


The Future of OrthoGuidelines


The OrthoGuidelines Process