Diagnostic Modalities for Acute Compartment Syndrome of the Extremities

Abstract

IMPORTANCE Acute compartment syndrome (ACS) can cause catastrophic tissue damage leading to permanent muscle and nerve loss. Acute compartment syndrome is a clinical diagnosis, with intracompartmental pressure (ICP) used in equivocal cases. There are no reliable diagnostic methods. The clinical evaluation is impossible to standardize, and the threshold for ICP has been known to be unreliable; thus, guidelines for diagnosis can result in overtreatment or delayed diagnosis.OBJECTIVE To present and review the advantages and disadvantages of each diagnostic modality and identify gaps that need to be addressed in the future and to review the most used and appropriate animal and human ACS models. EVIDENCE REVIEWWe included clinical studies and animal models investigating diagnostic modalities for ACS of the extremities. A MEDLINE and Web of Science search was performed. The protocol for the study was registered on PROSPERO (CRD42017079266). We assessed the quality of the clinical studies with Newcastle-Ottawa scale and reported level of evidence for each article.FINDINGS Fifty-one articles were included in this study, reporting on 38 noninvasive and 35 invasive modalities. Near-infrared spectroscopy and direct ICP measurement using a Stryker device were the most common, respectively. Cadaveric studies used saline infusions to create an ACS model. Most studies with human participants included injured patients with acquired ACS or at risk of developing ACS. In healthy human participants, tourniquets formed the most commonly used ACS model. Application of tourniquets and infusion of saline or albumin were the most used ACS models among animal studies. CONCLUSIONS AND RELEVANCEThis article reports on the most common as well as many new and modified diagnostic modalities, which can serve as inspiration for future investigations to develop more effective and efficient diagnostic techniques for ACS. Future studies on diagnostic modalities should include the development of tools for continuous assessment of ICP to better identify the earliest alterations suggestive of impending ACS. With the advent of such technologies, it may be possible to develop far less aggressive and more effective approaches for early detection of ACS.

Predictors of acute compartment syndrome of the lower leg in adults following tibial plateau fractures

“…ACS was defined as occurring within the first 24 h after initial trauma in patients with tibial plateau fractures and diagnosed based on the combination of clinical symptoms and physical examination with available objective diagnostic data of testing [ 5 , 19 ]. Furthermore, this definition was used widely in published studies [ 18 , 20 ].…”

Intraoperative acute compartment syndrome of the upper limb secondary to extravasation

“…A relatively new diagnostic modality is near-infrared spectroscopy which measures tissue hypoxia and could detect compartment syndrome 36 37. This non-invasive method however, is still the subject of much research to determine the threshold level to make a diagnosis 38. Similarly, the use of ultrasound to assess the fascial wall and detect an increase in compartment pressures has been reported but also requires further research 39.…”

“…Using ultrasound to assess blood flow can be useful when assessing the severity of compromised blood flow and has also been reported to rule out other vascular conditions such as deep vein thrombosis 40. The study of tissue hardness has also been investigated and showed promising results but is associated with limitations such as site of measurement and muscle contraction 38 41. Biomarkers such as creatine kinase or myoglobin can also be useful to aid diagnosis but requires a period of time before muscle injury causes a rise in levels 38.…”

“…The study of tissue hardness has also been investigated and showed promising results but is associated with limitations such as site of measurement and muscle contraction 38 41. Biomarkers such as creatine kinase or myoglobin can also be useful to aid diagnosis but requires a period of time before muscle injury causes a rise in levels 38. While there are other less prominent diagnostic aids for compartment syndrome, clinicians have to bear in mind that relying on a single diagnostic modality would be insufficient to make a firm diagnosis and correlation with the clinical picture is crucial.…”

Tibial anterior compartment compressibility in healthy subject, measured using compression sonography

“…Furthermore, soft tissue herniation into the needle and saline injections into the compartment can cause falsely high or low readings [5] . Next to measurement of direct intracompartmental pressure, newer methods to diagnose an acute compartment syndrome such as intramuscular partial pressure of oxygen [6] and near-infrared spectroscopy [7] have been introduced, but lack a reliable threshold and are not yet established [8] . There is still a lack of consensus in the area of the diagnosis [3] .…”