Evidence-based diagnosis and treatment recommendations for traumatic, severe limb injuries
ROSEMONT, Ill. (January 17, 2019)—The American Academy of Orthopaedic Surgeons (AAOS) released a new Clinical Practice Guideline (CPG) to help physicians develop their own evidence-based approach to diagnosing and treating adult patients with traumatic injuries at risk for acute compartment syndrome (ACS). ACS usually develops after a severe injury, such as a car accident or broken bone. Swelling or bleeding can occur within a limb compartment containing muscles, nerves, and blood vessels. Disrupting the flow of blood, oxygen and nutrients to the arms, legs, hands, feet and buttocks can damage nerve and muscle cells. It also can cause permanent disability and tissue death.
Development of this CPG was a collaborative effort between a volunteer workgroup of musculoskeletal trauma surgery experts, military surgeons and AAOS research staff—part of the Major Extremity Trauma and Rehabilitation Consortium. The workgroup used a standardized, rigorous approach and considered over 10,000 published studies on the management of acute compartment syndrome of the upper or lower extremity in adults.
“There is no strong literature to support any specific approach to the diagnosis and management of ACS. Clinicians need to remain vigilant for the onset of ACS in any patient presenting with limb swelling and be prepared to act immediately when the clinical situation demands,” says Andrew Schmidt, MD, Chief of the Department of Orthopedics at Hennepin Healthcare in Minneapolis, and Co-chair of the guideline workgroup. “In the absence of any sort of evidence-based standards, any and all clinical decisions regarding assessment and/or treatment of presumed ACS should be carefully documented in the patient’s medical record.”
CPG highlights include:
- limited evidence for the effectiveness of a reliable clinical, physical exam;
- moderate evidence that continuous or repeated compartment pressure measurements assist in the diagnosis of ACS when using a perfusion pressure of less than 30 mmHg;
- there are no specific evidence-based recommendations that can be made for any particular method of compartment pressure measurement. Laboratory biomarkers remain unproven in discerning ACS from other causes of muscle injury; and,
- fasciotomy, or surgical release of the involved compartments, needs to be done in a manner that results in complete decompression of the affected compartment. However, the CPG workgroup does not recommend performing fasciotomy in late stage ACS when there is evidence of irreversible muscle and nerve damage in the extremity.
The full Clinical Practice Guideline for Management of Acute Compartment Syndrome is intended for reference by orthopaedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website and free mobile app.
For more information on the development process for AAOS clinical practice guidelines, please view the Clinical Practice Guideline Methodology.
The American Academy of Orthopaedic Surgeons
With more than 38,000 members, the American Academy of Orthopaedic Surgeons (AAOS) is the world’s largest medical association of musculoskeletal specialists. The AAOS provides education programs for orthopaedic surgeons and allied health professionals, champions and advances the highest quality musculoskeletal care for patients, and is the authoritative source of information on bone and joint conditions, treatments and related issues.
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