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Review
May 1, 2019

Diagnostic Modalities for Acute Compartment Syndrome of the Extremities: A Systematic Review

Author Affiliations
  • 1Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
  • 2Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
  • 3Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
  • 4Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
JAMA Surg. 2019;154(7):655-665. doi:10.1001/jamasurg.2019.1050
Key Points

Question  What are the existing diagnostic modalities and research models for acute compartment syndrome (ACS)?

Findings  In this systematic review of 51 studies, near-infrared spectroscopy and direct intracompartmental pressure measurement using a Stryker device were the most commonly used methods, but all modalities lacked a reliable threshold. Of the most commonly used models, cadaveric studies used saline infusions; most studies with human patients included injured patients with acquired ACS or at risk of developing ACS; in healthy human patients, tourniquets formed the most commonly used ACS model; and application of tourniquets and infusion of saline or albumin among animal studies.

Meaning  Future studies on diagnostic modalities should include continuous assessment tools to better identify the earliest signs of ACS and thereby establish a reliable threshold.

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 Review  We 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 Relevance  This 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.

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    1 Comment for this article
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    Different approach using ultrasound to estimate intra-compartmental pressure
    Jakob Muehlbacher, MD | Department of Surgery, Division of General Surgery, Medical University Vienna, Vienna, Austria
    First and foremost, we would like to congratulate the authors for their detailed summary of current literature available for diagnostic modalities of the acute compartment syndrome of the extremities. Adding to this important review, we would like to refer to our recent published work on a different approach using ultrasound to estimate intra-compartmental pressure in a human post mortem experiment [1].
    We could demonstrate that ultrasound-based TFA measurement (TFA, tibia-fascia angle; the angle between the anterolateral cortex of the tibia and the fascia of the anterior compartment) is feasible and that compartment pressure can be well estimated by changes of
    TFA.
    Although our findings are too preliminary to be used in clinical practice now this non-invasive TFA measurement could be considered a sensible target for a clinical assessment.

    Reference
    1. Muhlbacher J, Pauzenberger R, Asenbaum U, Gauster T, Kapral S, Herkner H, et al. Feasibility of ultrasound measurement in a human model of acute compartment syndrome. World J Emerg Surg 2019;14:4.
    CONFLICT OF INTEREST: None Reported
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