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surgery.compartment-syndrome.core.v1

Acute Extremity Compartment Syndrome

emergencyacuteadultacuteinpatient
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Acute compartment syndrome — delta-P <30 mmHg triggers fasciotomy within 6h (McQueen criterion PMID 8898137). AAOS 2019 guidance + McQueen delta-P criterion are floor. Whitesides 1975 absolute thresholds are HISTORICAL. Sedated / obtunded patients REQUIRE pressure measurement (cannot self-report pain). Pediatric ACS: 3-A sign (anxiety + agitation + escalating analgesia) is the early clue. Pharmacotherapy does NOT treat ACS — only decompression. Drugs are adjunct for pain and rhabdo/AKI prevention. Workup workup.acute_compartment_syndrome registered in clinical-tools-registry. All PMIDs + RxCUIs live-verified 2026-05-26.

Entry points (7)

  • symptom
    Pain out of proportion to injury (EARLIEST sign) (AAOS 2019)
    pain_out_of_proportion_limb
  • symptom
    Pain with passive stretch of compartment muscles (EARLY) (AAOS 2019)
    pain_with_passive_stretch
  • symptom
    Tense, woody compartment on palpation (AAOS 2019)
    tense_woody_compartment
  • history
    High-energy trauma (tibial / forearm fracture, crush injury) (AAOS 2019)
    high_energy_extremity_trauma
  • history
    Post-revascularization reperfusion (>4-6h ischemia) (AAOS 2019)
    post_revasc_reperfusion
  • history
    Tight cast / bandage / circumferential burn eschar (AAOS 2019)
    tight_cast_or_bandage
  • lab_abnormality
    Rising CK + dark urine (myoglobinuria) (AAOS 2019)
    rising_ck_rhabdo

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Pediatric ACS presents with 3-A sign — anxiety + agitation + increasing analgesic requirement; alters threshold (AAOS 2019)
  • sbprequired
    vital • used at RED_FLAGS
    DBP enters delta-P calculation; hypotension lowers DBP and raises ACS risk at lower compartment pressures (McQueen 1996 PMID 8898137)
  • dbprequired
    vital • used at RED_FLAGS
    Delta-P = DBP minus compartment pressure; <30 mmHg = fasciotomy (McQueen 1996 PMID 8898137)
  • pulse_oximetry_limb
    vital • used at INITIAL_WORKUP
    Distal SpO2 + pulse — present early in ACS, absent late (do not rely on for diagnosis) (AAOS 2019)
  • cpkrequired
    lab • used at INITIAL_WORKUP
    Rhabdomyolysis monitoring; CK >5000 -> aggressive volume + bicarb for AKI prevention (AAOS 2019)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    AKI risk from rhabdo; baseline for trending (AAOS 2019)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Hyperkalemia from muscle necrosis (AAOS 2019)
  • urinalysis
    lab • used at INITIAL_WORKUP
    Myoglobinuria: positive blood on dipstick without RBCs (AAOS 2019)
  • lactate
    lab • used at INITIAL_WORKUP
    Ischemic muscle marker (AAOS 2019)
  • mechanism_of_injuryrequired
    history • used at CONTEXT
    Fracture / crush / reperfusion / burn / cast / IV infiltrate -> different risk profiles (AAOS 2019)
  • anticoagulation
    history • used at CONTEXT
    Anticoagulation raises bleeding into compartment risk (AAOS 2019)
  • sedated_intubated_obtunded
    history • used at CONTEXT
    Cannot self-report pain — REQUIRES pressure measurement (AAOS 2019)

12-phase flow (12)

  1. 1FRAME
    Confirm extremity compartment syndrome scope; differentiate from DVT, arterial occlusion, cellulitis (AAOS 2019)
    inputs: mechanism_of_injury
    advance: ACS in differential
  2. 2ENTRY
    Pain out of proportion + pain with passive stretch + risk factor (trauma / reperfusion / cast) (AAOS 2019)
    inputs: age
    advance: one entry trigger present
  3. 3CONTEXT
    Mechanism, time since injury / reperfusion, anticoagulation, ability to self-report pain (sedated -> pressure measurement mandatory) (AAOS 2019)
    inputs: mechanism_of_injury, anticoagulation, sedated_intubated_obtunded
    advance: context captured
  4. 4RED_FLAGS
    Late P findings (pallor, paresthesia, paralysis, pulselessness) = LIMB-THREATENING; do NOT wait for these. Tense compartment + pain with passive stretch + escalating analgesia = fasciotomy threshold (AAOS 2019)
    inputs: sbp, dbp
    advance: fasciotomy decision triggered or excluded
  5. 5INITIAL_WORKUP
    Compartment pressure measurement (Stryker / IV-pressure setup) for delta-P calculation in sedated / equivocal cases; CK, BMP, UA for rhabdo / AKI; lactate (AAOS 2019; McQueen 1996 PMID 8898137)
    inputs: cpk, creatinine, potassium, urinalysis
    actions: workup.acute_compartment_syndrome, panel.renal, panel.cbc
    advance: delta-P measured + labs back
  6. 6BRANCHING_WORKUP
    Imaging only if mechanism unclear (DVT vs ACS vs vascular injury); rarely needed if clinical ACS clear (AAOS 2019)
    advance: differential narrowed
  7. 7DIFFERENTIAL
    ACS vs phlegmasia cerulea dolens (DVT) vs acute limb ischemia (arterial) vs cellulitis vs DVT vs nerve injury (AAOS 2019)
    advance: differential resolved
  8. 8RISK_STRATIFICATION
    Delta-P <30 mmHg = fasciotomy within 6 hours (McQueen 1996 PMID 8898137); >12h ischemia = poor recovery; sedated patient with risk factors and pressure >30 absolute also fasciotomy
    inputs: dbp, cpk
    advance: delta-P threshold met or excluded
  9. 9TREATMENT
    EMERGENT FASCIOTOMY for delta-P <30 (or absolute >30 mmHg if sedated AND high clinical suspicion); remove circumferential cast / bandage / burn eschar (escharotomy); aggressive IV crystalloid for rhabdo / AKI; analgesia; monitor K (AAOS 2019)
    inputs: dbp, cpk, creatinine
    advance: fasciotomy completed or excluded
  10. 10DISPOSITION
    OR emergent for fasciotomy; ICU post-op if rhabdo / AKI / large fluid requirement; ward if isolated fasciotomy stable (AAOS 2019)
    inputs: sbp
    advance: destination assigned
  11. 11MONITORING
    Serial CK / BMP q4-6h x 24h; UOP target >0.5-1 mL/kg/h; wound check daily; delayed primary closure / skin graft at 3-7 days (AAOS 2019)
    inputs: cpk, potassium, creatinine
    actions: panel.renal
    advance: rhabdo resolving + wound healing
  12. 12FOLLOWUP
    Delayed primary closure / skin graft, PT for nerve recovery (Volkmann prevention), orthopedic follow-up at 2 weeks, peroneal nerve assessment (AAOS 2019)
    advance: reconstruction + rehab scheduled