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Published by American Academy of Orthopaedic Surgeons · AAOS Strength of Recommendation (Strong, Moderate, Limited, Consensus)
This guideline provides evidence-based recommendations for the diagnosis and treatment of acute compartment syndrome in adult patients with extremity trauma, addressing diagnostic criteria, pressure monitoring methods, fasciotomy techniques, and subsequent wound and fracture management.
Key Takeaways
The 2025 update is a Rapid Update of the 2018 guideline. The strength of recommendation for 'Associated Fracture' was upgraded from Consensus to Limited based on new evidence supporting operative fixation (external or internal) for initial stabilization of long bone fractures. Additional supporting evidence was added to various sections without changing other recommendations or the original scope.
Limited evidence supports that myoglobinuria and serum troponin level may assist in diagnosing acute compartment syndrome in patients with traumatic lower extremity injury.
Moderate evidence supports that, in patients with acute vascular ischemia, femoral vein lactate concentration sampled during surgical embolectomy may assist in the diagnosis of acute compartment syndrome.
Limited evidence supports that myoglobinuria does not assist in diagnosing acute compartment syndrome in patients with electrical injury.
In the absence of reliable evidence, it is the opinion of the work group that serum biomarkers do not provide useful information to guide decision making when considering fasciotomy for a presumed late-presentation or missed acute compartment syndrome.
Moderate evidence supports that intracompartmental pressure monitoring assists in diagnosing acute compartment syndrome.
Moderate evidence supports the use of repeated/continuous intracompartmental pressure monitoring and a threshold of diastolic blood pressure minus intracompartmental pressure >30 mmHg to assist in ruling out acute compartment syndrome.
In the absence of reliable evidence, it is the opinion of the work group that compartment pressure monitoring does not provide useful information to guide decision making when considering fasciotomy for an adult patient with evidence of irreversible intracompartmental (neuromuscular/vascular) damage.
Limited evidence supports using serial clinical exam findings to assist in ruling in acute compartment syndrome.
In the absence of reliable evidence, it is the opinion of the work group that without a dependable clinical examination (e.g. in the obtunded patient), repeated or continuous intracompartmental pressure measurements are recommended until acute compartment syndrome is diagnosed or ruled out.
In the absence of reliable evidence, it is the opinion of the work group that there are no reported diagnostic modalities, other than direct pressure monitoring or clinical exam findings, that provide useful information to guide decision making when considering fasciotomy for acute compartment syndrome.
In the absence of reliable evidence, it is the opinion of the work group that fasciotomy technique (e.g. one vs two incision, placement of incisions) is less important than achieving complete decompression of the compartments of the affected extremity.
In the absence of reliable evidence, it is the opinion of the work group that performing fasciotomy is not indicated in an adult patient with evidence of irreversible intracompartmental (neuromuscular/vascular) damage. Fracture stabilization, if warranted in these patients, should utilize a technique (external fixation/casting) that does not violate the compartment.
Limited evidence supports that operative fixation (external or internal) be performed for initial stabilization of long bone fractures with concomitant acute compartment syndrome requiring fasciotomy.
Limited evidence supports use of negative pressure wound therapy for management of fasciotomy wounds with regard to reducing time to wound closure and reducing need for skin grafting.
In the absence of reliable evidence, it is the opinion of the work group that neuraxial anesthesia may complicate the clinical diagnosis of acute compartment syndrome. If neuraxial anesthesia is administered, frequent physical examination and/or pressure monitoring should be performed.
Clinical Topic
Acute Compartment Syndrome
Objectives
To guide the clinician’s ability to diagnosis and treat acute compartment syndrome by providing evidence-based recommendations for key decisions that affect the management of patients with extremity trauma.
Target Patient Population
Adult patients with traumatized extremities.
Diagnostic Criteria
Clinical judgment based on serial clinical exam findings combined with repeated/continuous intracompartmental pressure monitoring (e.g., diastolic blood pressure minus intracompartmental pressure >30 mmHg).
Target Providers
Therapeutic Area
MusculoskeletalGuideline Scope
Inclusion Criteria
Exclusion Criteria
Care Settings
Special Populations
System: AAOS Strength of Recommendation (Strong, Moderate, Limited, Consensus)
Evidence Distribution
Recommendation Strength
Contraindications
Monitoring Guidance
In the absence of a dependable clinical examination, repeated or continuous intracompartmental pressure measurements are recommended until acute compartment syndrome is diagnosed or ruled out.
Difficulty
advanced
Learning Paths