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      The Pathophysiology, Diagnosis and Current Management of Acute Compartment Syndrome

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          Abstract

          Acute compartment syndrome (ACS) is a surgical emergency warranting prompt evaluation and treatment. It can occur with any elevation in interstitial pressure in a closed osseo-fascial compartment. Resultant ischaemic damage may be irreversible within six hours and can result in long-term morbidity and even death. The diagnosis is largely clinical with the classical description of ‘pain out of proportion to the injury’. Compartment pressure monitors can be a helpful adjunct where the diagnosis is in doubt. Initial treatment is with the removal of any constricting dressings or casts, avoiding hypotension and optimizing tissue perfusion by keeping the limb at heart level. If symptoms persist, definitive treatment is necessary with timely surgical decompression of all the involved compartments. This article reviews the pathophysiology, diagnosis and current management of ACS.

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          Most cited references62

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          Acute compartment syndrome. Who is at risk?

          We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure.
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            The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder?

            Todd Ulmer (2002)
            To assess whether published studies support basing the diagnosis of compartment syndrome of the lower leg on clinical findings. A MEDLINE search of the English literature from 1966 to 2001 was performed using "compartment syndromes" as the subject. A manual search of the bibliographies of retrieved articles and of major orthopaedic texts was also performed. Of 1,932 titles identified, 433 abstracts of potential relevance were reviewed, and 104 articles from relevant abstracts were examined in their entirety. Four studies met all eligibility criteria. Criteria for inclusion included the following: (a) target population, traumatic or iatrogenic tibia injuries; (b) diagnostic test, presence of data needed to calculate both the sensitivity and specificity of clinical findings; (c) outcome, the presence or absence of compartment syndrome; and (d) methodologic criteria, prospective study design. The likelihood ratio form of Bayes' theorem was used to assess the discriminatory ability of the clinical findings as tests for the compartment syndrome. There are limited data from which to define the usefulness of clinical findings for the diagnosis of compartment syndrome. Data from eligible studies suggest that the sensitivity of clinical findings for diagnosing compartment syndrome is low (13% to 19%). The positive predictive value of the clinical findings was 11% to 15%, and the specificity and negative predictive value were each 97% to 98%. These findings suggest that the clinical features of compartment syndrome of the lower leg are more useful by their absence in excluding the diagnosis than they are when present in confirming the diagnosis. Likelihood ratio calculations found that the probability of compartment syndrome with one clinical finding was approximately 25%, and the probability was 93% with 3 clinical findings present. However, these findings are based on limited information; because of the paucity of data available, the predictive value of the clinical findings for the diagnosis of compartment syndrome has yet to be defined.
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              Acute Compartment Syndrome: Update on Diagnosis and Treatment.

              Acute compartment syndrome can have disastrous consequences. Because unusual pain may be the only symptom of an impending problem, a high index of suspicion, accurate evaluation, and prophylactic treatment will allow the physician to intervene in a timely manner and prevent irreversible damage. Muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible. Ischemic injury begins when tissue pressure is 10 to 20 mm Hg below diastolic pressure. Therefore, fasciotomy generally should be done when tissue pressure rises past 20 mm Hg below diastolic pressure.
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                Author and article information

                Journal
                Open Orthop J
                Open Orthop J
                TOORTHJ
                The Open Orthopaedics Journal
                Bentham Open
                1874-3250
                27 June 2014
                2014
                : 8
                : 185-193
                Affiliations
                [1 ]Holland Orthopaedic and Arthritic Centre, Toronto, Canada
                [2 ]UCL Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, UK
                Author notes
                [* ]Address correspondence to this author at the 62 Hunter Street, Toronto, M4J 1C2, Canada; Tel: +1 416-967-8500; Fax: +1 416-967-8501; E-mail: jamesrdonaldson@ 123456gmail.com
                Article
                TOORTHJ-8-185
                10.2174/1874325001408010185
                4110398
                25067973
                a89eacbc-4c1f-4d03-a383-254540514b6f
                © Donaldson et al.; Licensee Bentham Open.

                This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

                History
                : 23 February 2014
                : 2 March 2014
                : 11 April 2014
                Categories
                Article
                Suppl 1

                Orthopedics
                compartment pressure monitoring,compartment syndrome,fasciotomy,ischaemic contracture,myofascial compartment.

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