AAOS Clinical Practice Guideline Summary

Management of Acute
Compartment Syndrome

Abstract
Col. Patrick M. Osborn, MD The Management of Acute Compartment Syndrome Clinical Practice
Andrew H. Schmidt, MD Guideline is based on a systematic review of current scientific and
clinical research. The purpose of this clinical practice guideline is to
guide the clinician’s ability to diagnose and treat acute compartment
syndrome by providing evidence-based recommendations for key
decisions that affect the management of patients with extremity
trauma. This guideline contains 15 recommendations including both
diagnosis and treatment. In addition, the workgroup highlighted the
need for better research in the diagnosis and treatment of acute
compartment syndrome.

Overview and Rationale result in prolonged hospital stays and

increased costs compared with those
The American Academy of Ortho- without compartment syndrome.
paedic Surgeons (AAOS), and the Developing ACS results in persis-
Major Extremity Trauma and Reha- tently poorer function and quality of
bilitation Consortium, with input life,2 and there are substantial
From San Antonio Military Health from representatives from the medicolegal implications in the
System, San Antonio, TX
Orthopaedic Trauma Association, diagnosis and treatment of com-
(Dr. Osborn), and Hennepin
Healthcare, Minneapolis, MN the Society of Military Orthopaedic partment syndrome that affect pa-
(Dr. Schmidt). Surgeons, representatives from San tients, providers, and the
Neither of the following authors nor Antonio Military Health System, and 3
healthcare system, alike. Combat
any immediate family member has the U.S. Air Force Critical Care Air casualties shoulder a significant
received anything of value from or has Transport Team, recently published burden of the condition, with 15%
stock or stock options held in a
their clinical practice guideline of combat limb injuries resulting in
commercial company or institution
related directly or indirectly to the (CPG), Management of Acute Com- fasciotomy,4 but this cohort also
subject of this article: Dr. Osborn and partment Syndrome (ACS).1 This showed a significant improvement
Dr. Schmidt. CPG was approved by the AAOS in patient outcomes with greater
This clinical practice guideline was Board of Directors in December focus on treating compartment
approved by the American Academy 2018 and has been officially syndrome. With appropriate edu-
of Orthopaedic Surgeons Board of
endorsed by the American College of cation to treating surgeons and
Directors on December 7, 2018.
Surgeons and the American Ortho- greater recognition of the potential
The complete document,
paedic Foot & Ankle Society. The diagnosis, US casualty mortality
Management of Acute Compartment
Syndrome Clinical Practice Guideline, purpose of this CPG is to diagnose and need for revision surgery were
includes all tables, and figures, and is and treat ACS based on current best decreased.5
available at www.aaos.org/ evidence. Therefore, the Department of
acsguideline.
The true incidence of ACS is Defense partnered with the AAOS to
J Am Acad Orthop Surg 2019;00:1-7 unknown as the treatment, fas- develop an evidence-based, CPG to
DOI: 10.5435/JAAOS-D-19-00270 ciotomy, essentially is the surrogate aid practitioners in the diagnosis and
for determining the diagnosis. treatment of ACS.1 Furthermore, the
Copyright 2019 by the American
Academy of Orthopaedic Surgeons. Although the economic burden of CPG represents a call for continued
ACS is unknown, these injuries can research to allow for more accurate

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CPG for Acute Compartment Syndrome

Figure 1 Guideline Summary

Collectively, these recommendations

create a framework for the evaluation
of patients at risk of compartment
syndrome with acute presentation
and those with an unclear history as
may be encountered with a crush
injury after opioid overdose, cer-
tainly a growing concern.6 The
guidelines highlight the current lim-
itations in diagnosing and treating
ACS. The best evidence available
suggests a role for certain bio-
markers and repetitive compartment
pressure monitoring as the most
reliable adjuncts to diagnosis. Most
questions regarding ACS have lim-
ited evidence or can only be ad-
dressed by a consensus statement
from the workgroup. There are sig-
nificant gaps in knowledge that
highlight a critical need for further
research.
This CPG provides orthopaedic sur-
Strength of recommendations categories.
geons and other physicians/providers
evidence-based principles to guide
the initial assessment and treatment
and reliable diagnostic methods and one regarding management were of patients at risk of compartment
treatments with less morbidity. An made. syndrome. These recommendations
exhaustive literature search was In summary, to create the ACS CPG, inform the development of appro-
conducted, resulting initially in over over 3,600 abstracts and more than priate use criteria to standardize and
200 articles for full review. The ar- 480 full-text articles were reviewed to improve the care of patients at risk of
ticles were then graded for quality develop 15 recommendations sup- extremity compartment syndrome.
and aligned with the workgroup’s ported by publications meeting strin- The overview that follows describes
patients, interventions, and out- gent inclusion criteria. Each the pertinent highlights and limi-
comes of concern. The workgroup recommendation is based on a system- tations of each recommendation.
used the established AAOS CPG atic review of the research-related topic Describing the nuances of the sup-
methods to generate eight consensus which resulted in three recom- porting evidence associated with each
statements regarding the diagnosis mendations classified as moderate, four recommendation provides context to
and treatment of compartment syn- as limited, and eight consensus state- aid appropriate application to patient
drome. Because of the lack of high- ments. The strength of recommenda- care.
quality evidence, only six recom- tion is assigned based on the quality of Laboratory tests (ie, biomarkers) are
mendations to guide diagnosis and the supporting evidence (Figure 1). frequently used when compartment

Management of Acute Compartment Syndrome Workgroup: Andrew Schmidt, MD (Co-chair), Colonel Patrick Osborn, MD (Co-chair),
Colonel (Ret.) Anthony Johnson, MD, FAOA, Luke Balsamo, MD, Marcus Philip Coe, MD, I. Leah Gitajn, MD, and Renee Greer, RN, BAN,
MSN. Nonvoting Oversight Chairs, Staff of the American Academy of Orthopaedic Surgeons, and Staff of the Major Extremity Trauma and
Rehabilitation Consortium: David Jevsevar, MD, MBA (Nonvoting Oversight Co-Chair), Julie B. Samora, MD, PhD, MPH (Nonvoting
Oversight Co-Chair), Ellen J. MacKenzie, PhD, Jayson Murray, MA, Kyle Mullen, MPH, Mary DeMars, Kaitlyn S. Sevarino, MBA, Peter
Shores, MPH, and Anne Woznica, MLIS, AHIP. Additional contributing members: Paul Sliwka, MPH, and Jennifer Chang, MPH. Former
AAOS Staff: Deborah S. Cummins, PhD.

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 Col. Patrick M. Osborn, MD and Andrew H. Schmidt, MD

Table 1
CPG Recommendations for the Use of Biomarkers (Serum or Urine) to Aid in the Diagnosis of ACS
Recommendation Strength Description of Level of Evidence

Serum lactate Moderate Moderate evidence supports that in patients with

acute vascular ischemia, femoral vein lactate
concentration sampled during surgical
embolectomy may assist in the diagnosis of
ACS.
Serum troponin Limited Limited evidence supports that serum troponin
may assist in diagnosing ACS in patients with
traumatic lower extremity injury.
Myoglobinuria Limited Limited evidence supports that myoglobinuria
may assist in diagnosing ACS in patients with
traumatic lower extremity injury.
Limited evidence supports that myoglobinuria
does not assist in diagnosing ACS in patients
with electrical injury.
Biomarkers in the late presentation of ACS Consensus In the absence of reliable evidence, it is the
opinion of the workgroup that serum biomarkers
do not provide useful information to guide
decision making when considering fasciotomy
for a presumed late presentation or missed ACS.

ACS = acute compartment syndrome

syndrome is suspected despite a lack present with limb swelling or other whole, these articles provide mod-
of clearly demonstrated diagnostic signs of a possible crush injury of erate evidence that compartment
benefit (Table 1). When evaluated unknown duration or onset. No pressure measurement assists in
from an evidence-based perspective, evidence was found to support using diagnosing ACS and that a perfusion
this CPG makes a limited recom- biomarkers to determine the pres- pressure of greater than 30 mmHg
mendation based on one moderate- ence of compartment syndrome in is safe for ruling out compartment
quality study7 that myoglobinuria presumed missed cases or late pre- syndrome. Similar to physical exam-
and serum troponin level may assist sentation, so their use is not recom- ination findings alone, pressure-based
in diagnosing ACS. This study mended to determine the safety of thresholds for diagnosing ACS may
included traumatic and vascular fasciotomy in these scenarios. result in overtreatment with fas-
causes of compartment syndrome, Measurement of intracompartmental ciotomy. The workgroup recom-
but not crush injury, and reported pressure is a well-established method mends against using single pressure
that elevated troponin levels were for diagnosing ACS; however, de- values alone for diagnosing com-
frequently used to decide on fas- spite the ubiquitous literature on partment syndrome and suggests that
ciotomy, but did not rule out the pressure measurement method, tim- clinical suspicion (the likelihood of
need for fasciotomy.7 There is lim- ing, and thresholds, only six studies compartment syndrome being pre-
ited evidence that myoglobinuria of low to moderate quality met the sent in the given clinical scenario) and
does not assist in diagnosing ACS in standards for inclusion in this CPG the additional use of clinical exami-
patients with electrical injury.8 In the (Table 2).10-15 Similar to studies on nation findings also be considered. In
very specific incidence of acute limb physical examination and clinical the challenging situation of an adult
ischemia caused by femoral artery findings, these studies used fas- patient with evidence of irreversible
embolism, a moderate recommen- ciotomy as a proxy for the diagnosis intracompartmental (neuromuscular/
dation is made that femoral vein of ACS. The included studies further vascular) damage, such as muscle
lactate concentration may assist in complicate concrete recommendations contracture or loss of normal neu-
the diagnosis of ACS.9 Additional because of the variability in the rologic function (neuromuscular/
evidence was also found regarding thresholds for fasciotomy, timing, and vascular) damage, such as muscle
the role of biomarkers in two other method of pressure monitoring (single contracture, the workgroup agreed
clinical situations. A particular reading versus continuous versus that compartment pressure moni-
challenge is posed by patients who serial measurement). Considered in toring does not provide useful

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CPG for Acute Compartment Syndrome

Table 2
CPG Recommendations for the Use of Intracompartmental Pressure Measurements to Aid in the Diagnosis of ACS
Recommendation Strength Description of Level of Evidence

ICP measurement Moderate Moderate evidence supports that ICP monitoring

assists in diagnosing ACS.
Serial ICP monitoring Moderate Moderate evidence supports the use of repeated/
continuous ICP monitoring and a threshold of
diastolic blood pressure minus ICP .30 mmHg
to assist in ruling out ACS.
ICP in late presentation ACS Consensus In the absence of reliable evidence, it is the
opinion of the workgroup 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.

ACS = acute compartment syndrome, CPG = clinical practice guideline, ICP = intracompartmental pressure

Table 3
CPG Recommendations for the Utility of Physical Examination to Aid in the Diagnosis of ACS
Recommendation Strength Description of Level of Evidence

Awake patient Limited Limited evidence supports using serial clinical

examination findings to assist in ruling in ACS.
Obtunded or intoxicated patient Consensus In the absence of reliable evidence, it is the
opinion of the workgroup that without a
dependable clinical examination (eg, in the
obtunded patient), repeated or continuous ICP
measurements are recommended until ACS is
diagnosed or ruled out.

ACS = acute compartment syndrome, CPG = clinical practice guideline, ICP = intracompartmental pressure

information to guide decision mak- be missed or attributed to other as- been published. However, at this
ing for fasciotomy. pects of injury. In obtunded patients, time, there is no evidence that other
Early diagnosis is essential and the workgroup found no evidence reported diagnostic modalities pro-
should be driven by a high index of regarding the utility of the clinical vide useful information to guide
suspicion based on the clinical his- examination in diagnosing ACS. decision making when considering
tory. In the setting of limb trauma, Therefore, the workgroup’s consen- fasciotomy.
physical examination has tradition- sus was that pressure-based methods When considering treatment
ally been considered the primary of diagnosis be used. (Table 5), no definitive evidence
method of diagnosis (Table 3). Recognizing the limitations of supports a specific method of fas-
However, the published evidence physical examination in the diagnosis ciotomy (eg, one or two incisions),
regarding the diagnostic perfor- of ACS, alternative, less-invasive given that complete decompression of
mance of clinical findings in the methods for diagnosing compart- the affected compartments is ach-
setting of ACS is quite limited. ment syndrome are sought (Table 4). ieved. When fasciotomy is performed,
Therefore only a limited recom- Numerous articles on potential there is a limited recommendation for
mendation supports serial physical diagnosis methods such as objective negative pressure wound dressings to
examination to diagnose ACS in determination of limb hardness or reduce the time to final closure and
awake patients due to poor speci- use of alternative technologies such need for skin grafting.16-19 In adult
ficity.10,11,14 The sensitivity of these as near-infrared spectroscopy, elec- patients with evidence of irreversible
signs is also suboptimal, as they can tromyography, and pH testing have intracompartmental injury, the

4 Journal of the American Academy of Orthopaedic Surgeons

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 Col. Patrick M. Osborn, MD and Andrew H. Schmidt, MD

Table 4
CPG Recommendations for Alternative Methods to Aid in the Diagnosis of ACS
Recommendation Strength Description of Level of Evidence

Alternative diagnostic methods Consensus In the absence of reliable evidence, it is the

opinion of the workgroup that there are no
reported diagnostic modalities (eg,
electromyography and infrared spectroscopy),
other than direct pressure monitoring or clinical
examination findings, that provide useful
information to guide decision making when
considering fasciotomy for ACS.

ACS = acute compartment syndrome, CPG = clinical practice guideline

Table 5
CPG Recommendations for the Management of Injuries With or at Risk for ACS
Recommendation Strength Description of Level of Evidence

Wound management after fasciotomy Limited Limited evidence supports the use of negative
pressure wound therapy for management of
fasciotomy wounds to reduce the time to wound
closure and need for skin grafting.
Fasciotomy methods Consensus In the absence of reliable evidence, it is the
opinion of the workgroup that the fasciotomy
technique (eg, one versus two incisions) is less
important than achieving complete
decompression of the compartments of the
affected extremity.
Late or missed ACS Consensus In the absence of reliable evidence, it is the
opinion of the workgroup 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 use a technique (external fixation/
casting) that does not violate the compartment.
Fracture management Consensus In the absence of reliable evidence, it is the
opinion of the workgroup that surgical fixation
(external or internal) should be performed for
initial stabilization of long bone fractures with
concomitant ACS requiring fasciotomy.
Neuraxial pain management Consensus In the absence of reliable evidence, it is the
opinion of the workgroup that neuraxial
anesthesia may complicate the clinical
diagnosis of ACS. If neuraxial anesthesia is
administered, frequent physical examination
and/or pressure monitoring should be
performed.

ACS = acute compartment syndrome, CPG = clinical practice guideline

consensus of the workgroup was that that does not violate the involved lization, including internal fixation,
fasciotomy is not indicated. Further- compartment. In contrast, the con- can be used. The workgroup also
more, in such a circumstance, if sensus of the workgroup was that in hoped to address the question of
fracture stabilization is needed, the patients with ACS undergoing fas- whether neuraxial anesthetic techni-
surgeon should consider a technique ciotomy, standard methods of stabi- ques might affect the diagnosis of

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CPG for Acute Compartment Syndrome

ACS in awake patients by masking new information to adjust and recommendation means that expert
the clinical symptoms. No literature optimize care for their patients. It is opinion supports the guideline rec-
was found that addressed this sce- also important that the utility of ommendation, although there is no
nario, and the consensus opinion of these guidelines in patient care be available empirical evidence that
the workgroup is that neuraxial validated. meets the inclusion criteria of the
anesthesia may complicate the clin- guideline’s systematic review.
ical diagnosis of ACS. The work-
group further recommends that if Recommendations
neuraxial anesthesia is administered References
in a patient at risk of developing The AAOS/Major Extremity Trauma
ACS, frequent physical examination and Rehabilitation Consortium Man- References printed in bold type are
and/or pressure monitoring should agement of Acute Compartment Syn- those published within the past 5
be performed. drome Clinical Practice Guideline are years.
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6 Journal of the American Academy of Orthopaedic Surgeons

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 Col. Patrick M. Osborn, MD and Andrew H. Schmidt, MD

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