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Acute compartment syndrome

Background

Overview

Definition
ACS is a serious condition characterized by increased pressure within a closed anatomical space, such as a limb compartment.
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Pathophysiology
The pathophysiology of ACS involves two primary mechanisms. First, the elevated pressure within the compartment can reduce tissue perfusion, leading to ischemia and potential tissue necrosis. Second, the increased pressure can compress nerves, blood vessels, and muscles within the compartment, leading to dysfunction and potential damage.
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Epidemiology
The incidence of ACS ranges from 1 to 7.3 per 100,000 person-years.
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Disease course
Clinically, ACS presents with a constellation of symptoms. These include pain that is out of proportion to the injury, pain on passive stretching of the muscles within the involved compartment, paresthesia, paralysis, and pallor. Complications include nerve damage, muscle dysfunction, and the development of secondary conditions like rhabdomyolysis and AKI.
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Prognosis and risk of recurrence
The prognosis is largely dependent on the timing of diagnosis and intervention. Early diagnosis and prompt surgical decompression, are known to be the best determinants of good outcomes. Delayed recognition and treatment can lead to serious complications, including permanent muscle and nerve damage, limb loss, and even death.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute compartment syndrome are prepared by our editorial team based on guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI 2021), the American Academy of Orthopaedic Surgeons (AAOS 2020), the British Orthopaedic Association (BOA 2014), and the Acute Limb Compartment Syndrome Working Group (ALCS-WG 2010). ...
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Diagnostic investigations

Indications for assessment
As per AAGBI 2021 guidelines:
Identify patients at risk of ACS on admission to the hospital or at the time of surgery.
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Obtain post-injury and postoperative ward observations and surveillance to identify signs and symptoms of ACS. Use objective scoring charts for ACS identification.
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  • Clinical examination

  • Serum biomarkers

  • Urine biomarkers

  • Other diagnostic modalities

Diagnostic procedures

Intracompartmental pressure measurement: as per AAOS 2020 guidelines, consider obtaining intracompartmental pressure monitoring to assist in diagnosing ACS.
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Medical management

BP control: as per BOA 2014 guidelines, maintain normal BP in patients with symptoms or clinical signs of acute decompression syndrome.
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Nonpharmacologic interventions

Removal of circumferential bandages: as per BOA 2014 guidelines, remove circumferential dressings and elevate the limb to heart level in all patients with symptoms or clinical signs of compartment syndrome.
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Therapeutic procedures

Fracture stabilization
As per AAOS 2020 guidelines:
Perform operative fixation (external or internal) for initial stabilization of long bone fractures with concomitant ACS requiring fasciotomy.
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Perform fracture stabilization using a technique (external fixation/casting) not violating the compartment in patients with evidence of irreversible intracompartmental (neuromuscular/vascular) damage.
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  • Neuraxial anesthesia

Surgical interventions

Indications for fasciotomy: as per AAOS 2020 guidelines, do not perform fasciotomy in adult patients with evidence of irreversible intracompartmental (neuromuscular/vascular) damage.
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More topics in this section

  • Fasciotomy technique

  • Wound care

Follow-up and surveillance

Surgical re-exploration: as per BOA 2014 guidelines, perform re-exploration at approximately 48 hours, or earlier if clinically indicated, in all patients.
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Quality improvement

Hospital requirements: as per AAGBI 2021 guidelines, ensure the availability of equipment for intracompartmental pressure measurement on wards caring for patients at risk of ACS. Ensure that the personnel is trained in its use and there are standard operating procedures available and implemented addressing the performance of such measurements and the urgent steps to be taken if measurements are abnormal.
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