Suspected Acute Compartment Syndrome
Clinical suspicion based on mechanism + symptoms
All Pathways
Orthopedic SurgeryEmergency
Acute Compartment Syndrome Management (AAOS 2025)
Acute Compartment Syndrome Management (AAOS 2025): Suspected Acute Compartment Syndrome → Clinical Assessment → High-Risk Factors → ⚠️ Neuraxial Anesthe...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Clinical Assessment
Evaluate for classic signs (6 Ps)
- Pain out of proportion to injury
- Pain with passive stretch (early, sensitive)
- Paresthesias (numbness/tingling)
- Pallor (late sign)
- Pulselessness (very late - often preserved)
- Paralysis (late sign - poor prognosis)
- Tense, swollen compartment on palpation
03Action High-Risk Factors
Identify patients at elevated risk
- Tibial shaft fracture (most common)
- Forearm fracture
- Crush injury
- Tight cast/dressing
- Reperfusion after vascular repair
- High-energy trauma
- Anticoagulation
- Obtunded/sedated patient
04Warning ⚠️ Neuraxial Anesthesia Caution
May mask ACS symptoms
- AAOS: Neuraxial anesthesia may complicate clinical diagnosis
- Monitor closely post-regional block
- Lower threshold for pressure measurement
- Consider general anesthesia if high ACS risk
05Decision Is clinical picture diagnostic?
Clear clinical ACS vs equivocal presentation
06Action Emergency Fasciotomy
Complete decompression of ALL involved compartments
- Within 6 hours of symptom onset (ideal)
- Leg: Release all 4 compartments
- Two-incision technique (anterolateral + posteromedial)
- Forearm: Volar and dorsal incisions
- Leave wounds open initially
- If associated fracture: External fixation OR internal fixation
07Action Fracture Stabilization
Stabilize associated fracture
- AAOS (Limited Evidence): Perform fixation for long bone fractures with ACS
- External fixation preferred if contamination
- Internal fixation acceptable if clean
- Technique should not violate compartment in late ACS
08Action Wound Management
Post-fasciotomy wound care
- NPWT may reduce time to closure (limited evidence)
- NPWT may reduce need for skin grafting
- Serial debridement if muscle necrosis
- Delayed primary closure or skin grafting at 48-72h
- Vessel loops for gradual closure
09Outcome Compartment Decompressed
Monitor for reperfusion, plan wound closure
- Path rejoins step 08Shared downstream outcome
10Action Remove External Constriction
Immediate temporizing measure
- Remove or bivalve cast completely
- Release all circumferential dressings
- Position limb at heart level (not elevated)
- Reassess symptoms immediately
11Action Measure Compartment Pressure
Use validated pressure monitoring device
- Stryker needle or arterial line setup
- Measure ALL compartments (leg: 4 compartments)
- Calculate delta pressure (ΔP)
- ΔP = Diastolic BP - Compartment Pressure
- ΔP ≤30 mmHg → High risk for ACS
- Absolute pressure >30 mmHg also concerning
12Decision ΔP ≤30 mmHg or absolute >30 mmHg?
Pressure threshold for surgical intervention
13Decision Evidence of irreversible damage?
Late presentation with established necrosis
- Symptoms >8-12 hours
- Fixed paralysis
- Anesthesia
- Muscle rigor
14Warning ⚠️ Late-Stage ACS - Do NOT Perform Fasciotomy
Fasciotomy contraindicated if irreversible damage
- AAOS: Do not perform fasciotomy in late-stage ACS
- Risk of infection, sepsis, need for amputation
- Fracture stabilization with external fixation/casting
- Do NOT violate the necrotic compartment
- Consider expectant management
- Staged amputation may be required
15Outcome Consider Amputation
If irreversible damage with systemic toxicity risk
- Path rejoins step 06Shared downstream outcome
16Action Serial Monitoring
If equivocal, repeat assessments
- Frequent neurovascular checks (q1-2h)
- Repeat pressure measurements
- Low threshold for surgical intervention
- Pain reassessment (may increase acutely)
- Path rejoins step 12Shared downstream outcome
- Path rejoins step 11Shared downstream outcome
Guideline Source
AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address pediatric patients
- Does not cover chronic exertional compartment syndrome
- Pressure measurement technique varies by institution
- Clinical diagnosis remains challenging - maintain high suspicion
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
Version 1Next review: 2028-01-01
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Related Resources
Frequently Asked Questions
What is the Acute Compartment Syndrome Management (AAOS 2025)?
The Acute Compartment Syndrome Management (AAOS 2025) is a emergency clinical algorithm for Orthopedic Surgery. It provides a structured decision tree to guide clinical decision-making, based on AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome.
What guideline is the Acute Compartment Syndrome Management (AAOS 2025) based on?
This algorithm is based on AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome (DOI: 10.5435/JAAOS-D-20-00686).
What are the limitations of the Acute Compartment Syndrome Management (AAOS 2025)?
Known limitations include: Does not address pediatric patients; Does not cover chronic exertional compartment syndrome; Pressure measurement technique varies by institution; Clinical diagnosis remains challenging - maintain high suspicion. Individual patient factors may require deviation from these recommendations.
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