Acute Compartment Syndrome: A Challenging and Time-Sensitive Diagnosis

When Miles O’Brien dropped a piece of TV equipment on his left forearm, he never imagined that he would end up having to have the arm amputated. He didn’t get his sore and swollen arm examined until two days after the initial injury. By that point, acute compartment syndrome had set in, and the built-up pressure severely damaged his nerves, arteries and veins, essentially killing the limb.

Acute compartment syndrome can be caused from something as simple as a badly bruised muscle in situations similar to O’Brien’s. Yet upwards of 75% of all acute compartment syndrome cases occur due to a broken limb, with tibial fractures being the most common cause.

Additionally, if a patient has a damaged blood vessel that has been blocked for several hours, caused by either injury or sleeping too long in one position, acute compartment syndrome can develop after the patient later regains motion and blood flow. However, this is most likely to occur in patients with neurological deficits or those who had been extremely intoxicated from alcohol or drug use.

Other causes of acute compartment syndrome can include burns, crush injuries, blood clots in a limb or vigorous exercise, especially involving movements that use extension under pressure.

(Watch one surgeon’s approach when a 73-old-male developed a large hematoma that further developed into compartment syndrome.)

Challenges of Compartment Syndrome Diagnosis

Major consequences can occur much faster than in O’Brien’s case. In fact, muscle necrosis can occur in as little as three hours after the injury in up to 37% of patients with acute compartment syndrome. Amputation was found to occur in 9.5% of acute leg compartment syndrome patients, and death occurred in 6.6%, according to a 2019 study.

Prompt diagnosis is key as acute compartment syndrome requires emergency fasciotomy. Typically, clinical symptoms known as “The Five Ps” (pain, pulselessness, paresthesia, paralysis, and pallor) can adequately diagnosis the syndrome in trauma patients with extremity injuries.

Yet there are some instances when diagnosis is not as straightforward. For instance, a patient may be unconscious and unable to report pain or paresthesia, and there may be times when there is a high clinical suspicion of acute compartment syndrome but the presentation is atypical. In these cases, an intracompartmental pressure monitor can be used as an adjunct to other diagnostic tools.

Biomarkers can also be considered as a means of diagnosis of compartment syndrome. A study published in the Journal of Trauma and Acute Surgery found that 92% of patients that had presented with a maximum creatine kinase (CK) level greater than 4,000 U/L were ultimately diagnosed with compartment syndrome. Of the 25 patients with maximum CK level greater than 4,000, 23 (92%) had CS, compared with 10 (30%) of the 33 patients who had maximum CK level of 4,000 or less”, i.e. compared with 30% who had maximum CK level of 4,000 or less.

When this factor was combined with the presence of elevated chloride levels, compartment syndrome occurred in 95% of patients. What’s more, when these CK and chloride levels were combined with a decreased presence of blood urea nitrogen, there was found to be a 100% chance of compartment syndrome.

In a review of malpractice litigation in compartment syndrome cases, ‘failure to diagnose’ was the most frequently cited claim (71.8% of cases), with the authors concluding that “lack of objective criteria for diagnosis increases the chances of medical errors and makes it an area vulnerable to litigation.”

In 2018, the Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons developed the Appropriate Use Criteria (AUC) for the Diagnosis and Management of Acute Compartment Syndrome. The clinical practice guidelines review the diagnostic roles of biomarkers, physical exams and pressure monitoring in 135 patient types. They also offer an online diagnostic and management tool.

Compartment Syndrome Fasciotomy: A Risk Balance

Failure to properly diagnosis acute compartment syndrome can lead to poor outcomes. In fact, 75% of compartment syndrome-related amputations were found to be associated with a delayed fasciotomy. Yet, performing unnecessary fasciotomies for suspected cases can also have detrimental outcomes. Fasciotomy is a major surgery that can involve long in-patient stays, risk of infection and scar contracture, and series of operations to ensure proper wound closure.

It is believed that nearly one-third of patients who undergo a fasciotomy will have a postoperative complication such as soft tissue necrosis, wound dehiscence, skin graft infection or need for tissue debridement, according to a report published in Trauma Care & Acute Surgery.

A study published in the Journal of Trauma and Acute Surgery found that 92% of patients with a maximum creatine kinase (CK) level greater than 4,000 U/L were diagnosed with compartment syndrome, while only 30% of patients with a maximum CK level of 4,000 or less were diagnosed with compartment syndrome.

Better Tools for Compartment Syndrome Diagnosis

In addition to the Appropriate Use Criteria (AUC) for the Diagnosis and Management of Acute Compartment Syndrome, advances in pressure monitoring may improve diagnosis accuracy and speed. For example, in May 2021, the FDA provided clearance for the use of the MY01 Continuous Compartmental Pressure Monitor that can provide continuous pressure measurements as opposed to single or repeated measurements.

When the device’s pressure sensor, which uses MEMS-based pressure-sensing technology, is inserted into the patient’s muscle compartments, the device provides pressure readings via Bluetooth technology for up to 18 hours.

The FDA previously cleared use of eight other pressure monitoring devices for acute compartment syndrome. These devices use either a fluid-filled slit catheter inserted in the compartment with an arterial line transducer to measure pressure or a syringe-based manometer to measure the resistance present when a small volume of saline solution is injected into the compartment.