Upper Extremity Compartment Syndrome Algorithm: Suspected compartment syndrome: forearm or hand → All patients: split the cast and release dressings now...
Pathway Overview
16 steps
16 total
Surgical emergency. Call the orthopaedic or hand surgery registrar now. Causes: forearm, elbow or hand fracture (supracondylar fracture in children), crush, reperfusion, tight cast or dressing, prolonged compression, IV or IO extravasation, burns, high-voltage electrical injury, high-pressure injection, bleeding on an anticoagulant, snakebite.
Do this at once. It must not delay theatre when the diagnosis is clear.
Swelling after a snakebite is usually a venom effect, not compartment syndrome. Do not operate on clinical signs alone.
Pain may be absent or hard to judge. Do not wait for late signs.
A clinical diagnosis. A palpable pulse does NOT exclude it. Record each exam and each analgesic dose with the time.
Yes: theatre now. No, equivocal, exam unreliable, or snakebite: measure compartment pressure.
Established irreversible muscle and nerve damage (for example, found down for many hours): non-operative care is usually preferred, with renal protection. Time alone does not prove it; if tissue may be viable, decompress.
Do not wait for pressure measurement or late signs when the diagnosis is clear. Complete decompression matters more than the incision choice.
Watch for reperfusion injury and rhabdomyolysis. Plan wound closure.
Continue rhabdomyolysis checks, wound plan and hand therapy.
Delta P = diastolic BP minus compartment pressure. Measure the BP at the same time.
Yes: consultant decision on fasciotomy now. No: compartment syndrome unlikely now; keep monitoring.
Combine the pressure with the clinical picture. Do not wait for late signs.
Compartment syndrome can still develop. Continue while the risk persists.
Yes: consultant review for fasciotomy now. No: continue hourly checks.
Keep hourly checks while the risk persists. Any new sign: repeat pressure and senior review.
AAOS Management of Acute Compartment Syndrome Evidence-Based Clinical Practice Guideline (2025 rapid update of the 2018 guideline)
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
Contraindicated Populations
Applicable Regions
AU: Snakebite: call the Poisons Information Centre 13 11 26 for clinical toxicologist advice before any fasciotomy. Emergency: 000.
UK: BOASt Diagnosis and Management of Compartment Syndrome of the Extremities (updated July 2025): hourly assessment; consultant decides on fasciotomy when delta P is below 30 mmHg.
US: AAOS ACS CPG 2025: repeated or continuous delta P above 30 mmHg helps rule out ACS.
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The Upper Extremity Compartment Syndrome Algorithm is a diagnostic clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on AAOS Management of Acute Compartment Syndrome Evidence-Based Clinical Practice Guideline (2025 rapid update of the 2018 guideline).
This algorithm is based on AAOS Management of Acute Compartment Syndrome Evidence-Based Clinical Practice Guideline (2025 rapid update of the 2018 guideline).
Known limitations include: Children: most evidence is from adults and the delta P threshold is less certain; get paediatric orthopaedic advice early.; Pressure thresholds support, not replace, clinical judgement; one reading can mislead, so repeat or monitor continuously.; Snakebite, burns and high-pressure injection injuries need specialist input (toxicology, burns, hand surgery).; Not for chronic exertional compartment syndrome or the lower limb.. Individual patient factors may require deviation from these recommendations.
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