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
Biomarkers - Myoglobinuria and Serum Troponin
Limited evidence supports that myoglobinuria and serum troponin level may assist in diagnosing acute compartment syndrome in patients with traumatic lower extremity injury.
Limited Evidence Limited Evidence

One moderate quality study (Alamshah, 2016) showed that myoglobinuria had a moderate/strong relationship to the reference standard of fasciotomy, although surgery was performed based on unspecified pressure measurements and clinical criteria. This study also showed troponin levels to be a strong rule-in test (elevated values were associated with fasciotomy) but a poor rule-out test (normal values were not associated with absence of fasciotomy). This paper included 149 patients, of which 82% had trauma and the others had vascular injury. Patients with crush injury were excluded, which is of interest because this is the classic condition that causes myoglobinuria. Fasciotomy was performed in 14 cases, but the indications for fasciotomy are unclear. This paper does not provide enough data to support any specific role for myoglobinuria as a diagnostic indicator for when acute compartment syndrome is present, but suggests that myoglobinuria is more common in patients with leg trauma (but without crush injury) who undergo fasciotomy.

FUTURE RESEARCH

Future research examining the sensitivity and specificity of biomarkers compared to an appropriate reference standard (e.g. validated and/or comprehensive clinical and pressure diagnosis) in a population of patients suspected of ACS would be invaluable.

Serum Biomarkers - Femoral Vein Lactate Concentration
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.
Moderate Evidence Moderate Evidence

One high quality study (Mitas, 2014) of patients with acute limb ischemia from femoral artery embolism reported serial lactate measurements taken from the femoral vein just before and at several time points following limb revascularization. The results showed a strong relationship between the difference in blood lactate concentration immediately before and after revascularization and the reference standard of fasciotomy (which was performed based on clinical findings of new sensorimotor deficits and/or intracompartment pressure greater than 30 mmHg). This strong relationship to the reference standard held true at any threshold of blood lactate level between 1 and 3 mmol/L. Although the pressure criterion used could be considered an overly conservative indication for fasciotomy, the findings show that compartment syndrome is more likely when a more profound metabolic disturbance is present. It is important to recognize that this diagnostic approach is only applied ACS occurring in non-trauma patients with acute lower limb ischemia from femoral artery embolism.

FUTURE RESEARCH

Future research examining the sensitivity and specificity of biomarkers compared to an appropriate reference standard (e.g. validated and/or comprehensive clinical and pressure diagnosis) in a population of patients suspected of ACS would be invaluable.

Biomarkers - Electrical Injury
Limited evidence supports that myoglobinuria does not assist in diagnosing acute compartment syndrome in patients with electrical injury.
Limited Evidence Limited Evidence

An uncommon cause of extremity compartment syndrome is high-voltage electrical injury, and the diagnosis of ACS in this group is complicated by the associated eschar and the fact that these patients are most-often intubated and cared for in an intensive care unit setting. Biochemical monitoring is therefore of interest in this subset of patients. One moderate quality study (Cancio, 2005) found a weak/poor association between myoglobinuria and the reference standard of fasciotomy (performed based on “clinically evident extremity compartment syndrome or elevated compartment pressures”) for diagnosis of ACS in patients with electrical burn injuries. In relation to this study, neither compartment pressure monitoring nor clinical exam findings have been validated for ACS diagnosis, and treatment standards are biased towards performing fasciotomy/escharotomy. Although there was a weak association between myoglobinuria and performance of fasciotomy in patients with high-voltage electrical injury, the sensitivity and specificity of myoglobinuria are insufficient to recommend it as a diagnostic modality.

FUTURE RESEARCH

Future research examining the sensitivity and specificity of biomarkers compared to an appropriate reference standard (e.g. validated and/or comprehensive clinical and pressure diagnosis) in a population of patients suspected of ACS would be invaluable.

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.
Consensus Consensus

All information available and consideration of the risk of a potentially late fasciotomy should be considered.

POSSIBLE HARMS OF IMPLEMENTATION

As noted in this CPG, the diagnosis of ACS at any time point after injury is difficult, uncertain, and potentially controversial, with significant practice variation present. Laboratory value abnormalities alone do not provide sufficient guidance to indicate when fasciotomy is needed. Presuming a missed ACS based on biomarkers may lead to performing fasciotomy on a necrotic compartment with resultant complications. Surgeons should consider irrigation and debridement of an affected limb when faced with evidence of significant infection in an extremity with a presumed missed ACS.

FUTURE RESEARCH

While reliable diagnostic criteria for ACS may remain elusive, research should be geared towards determining serum markers that differentiate between reversible ischemia caused by ACS and indicators of neuromuscular necrosis that increases the morbidity of fasciotomy.

Pressure Methods - Diagnosis
Moderate evidence supports that intracompartmental pressure monitoring assists in diagnosing acute compartment syndrome.
Moderate Evidence Moderate Evidence

There are 2 moderate quality studies (McQueen 2013, Janzing 2001) and 3 low quality studies (Sangwan 2003, Mubarak 1978, Dickson 2003) evaluating the sensitivity and specificity of compartment pressure monitoring for diagnosing ACS. Variability in defining ACS, the type and duration of compartment pressure monitoring (single reading vs. continuous vs. intermittent), and the threshold for fasciotomy complicate interpretation of these studies. However, in all of the studies where a differential pressure of 30 mmHg was used as a cutoff (diastolic blood pressure-ICP or mean arterial pressure- ICP), pressure monitoring showed good sensitivity and/or specificity, indicating that, when combined with clinical symptoms, pressure monitoring can be useful in ruling out compartment syndrome. There was not adequate evidence to support a single absolute pressure cutoff to diagnose ACS.

One moderate strength study (McQueen 2013) examined the sensitivity of continuous compartment pressure monitoring with a threshold for fasciotomy of DBP-ICP <30 for >2 consecutive hours. This study also attempted to quantify false positives and false negatives based on intraoperative findings and clinical sequelae, which lends the study practical strength. While this study found DBP-ICP < 30 to have high sensitivity and specificity, another moderate quality study (Janzing 2001) found this threshold to have poorer specificity, indicating that using DBP-ICP < 30 to diagnose compartment syndrome will result in unnecessary fasciotomies (false positives). The three lower quality studies (Sangwan 2003, Murbarak 1978, Dickson 2003) showed that using DBP-ICP < 30 to diagnose compartment syndrome had good specificity, but were variable in their findings as to the sensitivity of the test.

The findings of another low quality study looking at continuous pressure monitoring vs. no pressure monitoring for tibia fractures (McQueen 1996) supports the fact that few compartment syndromes will be missed using DBP-ICP<30 as a cutoff for diagnosing ACS.

POSSIBLE HARMS OF IMPLEMENTATION

Using a threshold of DBP-ICP <30 to diagnose compartment syndrome might lead to overtreatment
(fasciotomies for patients without true compartment syndrome). Relying on a single pressure reading as
opposed to serial or continuous compartment readings is not a reliable way to diagnose compartment
syndrome and may result in missed compartment syndrome. Relying solely on pressure readings should
be avoided: clinical suspicion and clinical exam must factor into diagnosis as well.

FUTURE RESEARCH

 Further studies examining the sensitivity and specificity of pressure measuring methods, techniques and
thresholds vs. reference standards that take into account false negatives and false positives would be
beneficial.

Pressure Methods - Ruling Out
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.
Moderate Evidence Moderate Evidence

There are 2 moderate quality studies (McQueen 2013, Janzing 2001) and 3 low quality studies (Sangwan 2003, Mubarak 1978, Dickson 2003) evaluating the sensitivity and specificity of compartment pressure monitoring for diagnosing ACS. Variability in defining ACS, the type and duration of compartment pressure monitoring (single reading vs. continuous vs. intermittent), and the threshold for fasciotomy complicate interpretation of these studies. However, in all of the studies where a differential pressure of 30 mmHg was used as a cutoff (diastolic blood pressure-ICP or mean arterial pressure- ICP), pressure monitoring showed good sensitivity and/or specificity, indicating that, when combined with clinical symptoms, pressure monitoring can be useful in ruling out compartment syndrome. There was not adequate evidence to support a single absolute pressure cutoff to diagnose ACS.

One moderate strength study (McQueen 2013) examined the sensitivity of continuous compartment pressure monitoring with a threshold for fasciotomy of DBP-ICP <30 for >2 consecutive hours. This study also attempted to quantify false positives and false negatives based on intraoperative findings and clinical sequelae, which lends the study practical strength. While this study found DBP-ICP < 30 to have high sensitivity and specificity, another moderate quality study (Janzing 2001) found this threshold to have poorer specificity, indicating that using DBP-ICP < 30 to diagnose compartment syndrome will result in unnecessary fasciotomies (false positives). The three lower quality studies (Sangwan 2003, Murbarak 1978, Dickson 2003) showed that using DBP-ICP < 30 to diagnose compartment syndrome had good specificity, but were variable in their findings as to the sensitivity of the test.

The findings of another low quality study looking at continuous pressure monitoring vs. no pressure monitoring for tibia fractures (McQueen 1996) supports the fact that few compartment syndromes will be missed using DBP-ICP<30 as a cutoff for diagnosing ACS.

POSSIBLE HARMS OF IMPLEMENTATION

Using a threshold of DBP-ICP <30 to diagnose compartment syndrome might lead to overtreatment
(fasciotomies for patients without true compartment syndrome). Relying on a single pressure reading as
opposed to serial or continuous compartment readings is not a reliable way to diagnose compartment
syndrome and may result in missed compartment syndrome. Relying solely on pressure readings should
be avoided: clinical suspicion and clinical exam must factor into diagnosis as well.

FUTURE RESEARCH

Further studies examining the sensitivity and specificity of pressure measuring methods, techniques and
thresholds vs. reference standards that take into account false negatives and false positives would be
beneficial.

 

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.
Consensus Consensus

Determining when ACS has caused irreversible damage to the nerves, vessels and/or muscle in a given compartment is difficult in the absence of a reliable clinical history. There is no convincing clinical data to indicate that multiple compartment pressure checks can help determine when irreversible damage has occurred. There is also no conclusive clinical data to suggest that elevated compartment pressures in a patient with known irreversible intracompartmental damage are an indication for fasciotomy. Fasciotomy performed on a limb with irreversible intracompartmental damage carries significant morbidity.

POSSIBLE HARMS OF IMPLEMENTATION

The indication for fasciotomy should be based on a reliable clinical history and exam. Assuming the viability of the compartment necrosis can lead to a missed diagnosis while performing fasciotomy on a necrotic compartment may lead to significant morbidity.

FUTURE RESEARCH

Determining reliable compartment pressure measurements that indicate the progression to irreversible ischemia would significantly aid the clinician seeking to avoid the morbidity of fasciotomy in this population.

Physical Exam (Awake)
Limited evidence supports using serial clinical exam findings to assist in ruling in acute compartment syndrome.
Limited Evidence Limited Evidence

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.

POSSIBLE HARMS OF IMPLEMENTATION

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.

FUTURE RESEARCH

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.

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.
Consensus Consensus

A high suspicion for compartment syndrome should always be maintained in the obtunded patient. In contradistinction to the patient with an unknown clinical timeline leading to compartment syndrome, the timeline of the obtunded patient’s clinical course might be more obvious. Mechanism and/or previous surgical interventions (i.e. vascular repair, ORIF) should alert surgeons to the potential for ACS, and we recommend that surgeons closely monitor these patients and ensure that appropriate perfusion is maintained and hypotension avoided. With at-risk patients and equivocal findings of acute compartment syndrome, fasciotomy is less morbid than the consequences of a missed acute compartment syndrome.

POSSIBLE HARMS OF IMPLEMENTATION

In this patient population, there is limited risk in performing serial examination of the affected extremity. Increased risk may be introduced if an inappropriate threshold is used to diagnosis acute compartment syndrome in these patients allowing acute compartment syndrome to evolve into irreversible intracompartmental damage.

FUTURE RESEARCH

Further studies examining the sensitivity and specificity of pressure measuring methods, techniques and thresholds vs. reference standards that take into account false negatives and positives, as done by McQueen 2013, would be beneficial.

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.
Consensus Consensus

Only one low quality study (Dickson, 2003) meeting the inclusion criteria for this CPG was found that addressed any diagnostic modalities other than clinical or pressure testing. This study showed that in patients with a clinical diagnosis suggesting or confirming compartment syndrome, a “hardness ratio” of 2 or more had a weak association to the reference standard of a clinical diagnosis of ACS (as determined by the attending physician’s clinical assessment). Hardness measurements were made using an investigational device consisting of a force plate that was applied to the skin. The hardness of the compartment with the highest compartment pressure was comparted to the final clinical assessment, and diagnostic parameters calculated. In particular, this diagnostic method had low specificity, resulting in a significant number of false positive diagnoses, leading the authors not to recommend this as a useful diagnostic modality.

Many other examples of alternative diagnostic modalities have been considered to be of potential value for the diagnosis of ACS, including near-infrared spectroscopy (NIRS), electromyography (EMG), and pH testing. However, at the time of publication of this CPG, these modalities were not supported by any published literature meeting the inclusion criteria for this review. It is the opinion of the panel that this is an area of significant research with potential clinical impact, and readers should continue to review the published literature as new data regarding new diagnostic modalities for ACS become available.

POSSIBLE HARMS OF IMPLEMENTATION

Misdiagnosis could lead irreversible intracompartmental damage.

FUTURE RESEARCH

Studies examining the sensitivity and specificity of various diagnostic modalities (e.g. NIRS, Imaging, NCS, etc.) as compared to an appropriate reference standard (e.g. validated and/or comprehensive clinical and pressure diagnosis) in a population of patients suspected of ACS may have significant impact on clinicians’ ability to accurately diagnose acute compartment syndrome in a timely fashion.

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.
Consensus Consensus

Four low quality studies (Bible, 2013; Jang, 2017; Kanj, 2013; Heemskerk, 2003) examined various fasciotomy techniques displaying varying results and inconsistent outcomes, which led to the lack of an evidence-based recommendation for this topic.

Clinicians should consider the soft tissue envelope when determining incision placement as the literature does not clearly suggest an advantage or disadvantage for choosing different techniques. Surgeons should choose the fasciotomy technique deemed best to allow for full decompression of the involved compartments and may be tailored to other considerations such as plans for staged fixation. For the inexperienced clinician, it is recommended that the 2-incision method be used.

POSSIBLE HARMS OF IMPLEMENTATION

Incomplete fasciotomy can have severe consequences. In the war wounded, the need for fasciotomy revision is associated with a 4-fold increase in mortality.

FUTURE RESEARCH

While fasciotomy is not technically challenging, research into the most effective educational tools to improve fasciotomy techniques may be of benefit. A fasciotomy education program, as conducted in the U.S. military, improved survival rates however, the rates of delayed fasciotomy did not change.

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.
Consensus Consensus

Patients may present with evidence of advanced compartment syndrome of uncertain but likely prolonged duration, as in the case of a patient found obtunded or incapacitated. When evidence of irreversible muscle ischemia and necrosis (rhabdomyolysis) is observed, as indicated by the presence of myoglobinuria, renal failure, and dramatic elevations in creatine phosphokines (CPK), fasciotomy may increase the potential for further reperfusion injury. In addition, exposure of necrotic muscle by performing fasciotomy may necessitate extensive debridement and create large wounds with the potential for soft tissue infection. For these reasons, the panel recommends that fasciotomy not be performed in such circumstances. In such cases where there is an associated fracture, operative fracture care should be approached with caution and fixation methods that do not violate the compartment (external fixation, casting) should be considered.

POSSIBLE HARMS OF IMPLEMENTATION

When presented with the possibility of late ACS, clinicians should be wary of erroneously assuming the patient has an irreversible injury. In the absence of any reliable techniques to accurately determine the timing of the compartment syndrome, the clinician is left with few options. Fasciotomies in an extremity with irreversible compartment syndrome can lead to systemic reperfusion injuries and exposes devitalized muscle potentially increasing the risk of infection. A small incision to determine the presence or absence of devitalized muscle in the compartment may be a reasonable option. If necrotic muscle is found, extension of the incision is not advised. Fracture stabilization is warranted in these extremities in certain situations. In the short term, temporizing stabilization with external fixation or casting is preferred.

FUTURE RESEARCH

Future research to define serum biomarkers or determine imaging modalities that reliably establish the extent of muscle necrosis would be beneficial.

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.
Consensus Consensus

One low quality study (Kim, 2017) supports the use of either immediate intramedullary nailing or internal fixation in tibial fractures requiring fasciotomy. This study retrospectively reviewed a small cohort of patients who underwent fasciotomy with concomitant intramedullary nailing, internal plate fixation, or external fixation. Patients later underwent delayed fasciotomy closure or skin grafting. The investigators found no difference in functional outcomes or complications.

POSSIBLE HARMS OF IMPLEMENTATION

Early internal fixation with open fasciotomy wounds may lead to contamination of hardware and deep infection. The above study must be interpreted with caution.

FUTURE RESEARCH

In the absence of studies randomizing patients requiring fasciotomy for ACS to either internal or external fixation, analysis of complications and patient outcomes in large, matched, stratified, controlled treatment groups at equal follow up times would be beneficial.

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.
Limited Evidence Limited Evidence

There was one moderate strength (Li, 2015) and three low strength (Zannis, 2009; Mittal, 2017; Krticka, 2016) studies evaluating wound management after fasciotomy. Li et al. found that use of negative pressure wound therapy resulted in a decrease in days to wound closure/coverage (9 days versus 14 days). Zannis et al. found that negative pressure wound therapy resulted in decreased need for split thickness skin graft in both the lower limb (17% versus 44%, RR 0.39) and upper limb (43% versus 66%, RR 0.67).

Of the three studies that reported important but rare outcomes including infection and/or other complications, all were underpowered to adequately assess these rare outcomes (subject sizes: 52 patients in Li et al., 63 patients in Krticka et al. and 50 patients in Mittal et al.). Krticka 2016 compared vacuum-assisted closure with dermatotaxis technique versus dressing fabrics and reported that dressing fabrics resulted in a higher rate of infection that was not statistically significant (9.5% versus 14.3%). For context, based on this rate of infection a study would require 1,478 patients (739 per group) to be adequately powered to detect a statistically significant difference with 80% power, assuming an alpha of 5%.

Mittal et al. compared two specific dermatotaxis techniques to aid wound closure without use of negative pressure wound therapy and found that use of tensioned wires (as opposed to sutures) resulted in higher risk of infection (12% versus 4%, RR 3).

POSSIBLE HARMS OF IMPLEMENTATION

We believe that there is no harm associated with use of negative pressure wound therapy to assist wound management/wound closure of fasciotomy wounds, particularly if used in the short term. However, there may be a relationship between time to wound closure/coverage and risk of infection, particularly in the setting of metallic implants. However, this is not been examined in the literature in this patient population. Furthermore, the risk benefit ratio of dermatotaxis techniques are not yet clear.

FUTURE RESEARCH

Future research is needed to further clarify the relative benefits associated with use of negative pressure wound therapy, with particular consideration for austere environments. This work has important implications for forward surgical teams utilized by the military. However, there may be barriers to performing this work in civilian settings due to the substantial benefits of negative pressure wound therapy in terms of patient care (fewer dressing changes, easier nursing care) as well as theoretical benefits (including reduction in nosocomial contamination due to sterile placement in the operating room, improved granulation tissue formation to improve skin graft bed). Adequately powered high quality studies are needed to explore the relationship between management of fasciotomy wounds and complication such as infection as well as rate of and time to delayed wound closure and/or skin graft. Independent variables important to study include type of wound care method (ie negative pressure wound therapy versus wet to dry guaze), use of dermatotaxis techniques (ie “Jacob’s ladder” or “shoestring” technique versus traditional), time to closure or skin graft, timing for definative fixation/definative hardware. Both hard outcomes as well as functional outcomes and health-related quality of life outcomes are needed to adequately guide decision-making.

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.
Consensus Consensus

As there is no objective, gold standard for the diagnosis of acute compartment syndrome, the clinician should seek an aggregate of data points (including physical examination findings, escalating need for pain medication, pain out of proportion of injury, perfusion pressure, absolute pressure). At the present, in the absence of adequate studies, we believe that the risk of neuraxial anesthesia delaying and/or masking signs/symptoms associated with impending compartment syndrome (including physical examination findings, need for pain medication, magnitude of pain) outweighs the potential benefits of this treatment modality in high risk patient populations. We acknowledge that this opinion is made in the setting of only isolated extremely low-quality case reports and case series, none of which meet standards for inclusion in this analysis. The current literature suggests both that regional anesthesia may delay diagnosis of acute compartment syndrome and that regional anesthesia does not mask timely diagnosis. If neuraxial anesthesia is administered, we recommend that more emphasis is placed on intra-compartmental pressure monitoring as well as break through pain despite regional anesthesia.

Furthermore, we believe that clinicians should be attentive to quantity of narcotic pain medications administered to patients as an indicator of impending acute compartment syndrome.

Possible Harms Of Implementation

Both delayed diagnosis of acute compartment syndrome and the increased utilization of narcotic pain medication increase risk for adverse outcomes. Excessive and prolonged narcotic use can lead to substantial patient harm however, there may be a role for neuraxial anesthesia to decrease acute narcotic use and, potentially, subsequent dependence. In patients with severe cardiopulmonary disease general anesthesia may carry substantially increased risk of anesthesia- associated complication – in this setting clinicians and patients must carefully weigh the risk/benefit ratio of neuraxial anesthesia versus general anesthesia.

Future Research

High quality studies are needed to assess the ability to diagnose acute compartment syndrome in the setting of regional anesthesia. Similar to the obtunded patient, patients who may benefit from neuraxial anesthesia would benefit from improved monitoring for compartment syndrome. Further studies are also needed evaluate the relationship between regional anesthesia and the development of chronic pain/chronic opioid use.


ACKNOWLEDGEMENTS

Guideline Work Group:
Andrew Schmidt, MD, Chair
Colonel Patrick Osborn, MD, Vice-Chair
Colonel Anthony Johnson, MD, FAOA
Luke Balsamo, MD
Marcus Philip Coe, MD
I. Leah Gitajan, MD
Renee Greer, RN, BAN, MSN


Oversight Chairs:
David Jevsevar, MD, MBA
Julie B. Samora, MD, PhD, MPH

AAOS/METRC Staff:
Ellen J. MacKenzie, PhD Dean of Bloomberg School of Public Health
Jayson Murray, MA AAOS Director of Clinical Quality and Value
Kyle Mullen, MPH AAOS Manager of Clinical Quality and Value Development
Mary DeMars AAOS Clinical Quality and Value Coordinator
Kaitlyn S. Sevarino, MBA AAOS Manager of Clinical Quality and Value Implementation 
Peter Shores, MPH AAOS Biostatistician
Anne Woznica, MLIS AHIP AAOS Medical Research Librarian

Additional Contributing Members:
Paul Sliwka
Jennifer Chang

Former AAOS Staff:
Deborah S. Cummins, PhD

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