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Emergency Surgery 3: Diagnosis and Treatment of Acute Extremity Compartment Syndrome
Emergency Surgery 3: Diagnosis and Treatment of Acute Extremity Compartment Syndrome
Emergency surgery 3
Diagnosis and treatment of acute extremity compartment
syndrome
Arvind G von Keudell, Michael J Weaver, Paul T Appelton, Donald S Bae, George S M Dyer, Marilyn Heng, Jesse B Jupiter, Mark S Vrahas
Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineective Lancet 2015; 386: 12991310
treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle See Editorial page 1212
dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which This is the third in a Series of
acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of three papers about emergency
surgery
intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive
surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce Orthopedic Trauma Initiative
at Harvard Medical School,
intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in Boston, MA, USA
The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment (A G von Keudell MD,
syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and M J Weaver MD,
propose a clinical guideline based on the available data. P T Appelton MD, D S Bae MD,
G S M Dyer MD, M Heng MD,
Prof J B Jupiter MD,
Introduction functions of fascia are providing attachment sites for Prof M S Vrahas MD);
Acute extremity compartment syndrome is a surgical muscles, maintaining the position of muscle groups Department of Orthopedic
Surgery, Massachusetts General
emergency for which timely diagnosis is essential. during motion, and improving the mechanical advantage
Hospital, Harvard Medical
Although described around 130 years ago,1 this disorder of muscle during contraction.15 Deep investing fascia is School, Boston, MA, USA
remains challenging to diagnose and treat eectively. Acute innervated and might also play a part in muscle (G S M Dyer, M Heng,
extremity compartment syndrome is dened similarly to coordination and proprioception.16 The dense brous Prof J B Jupiter, Prof M S Vrahas);
Department of Orthopedic
many other compartment syndromes: an increase in nature of fascia creates a dened anatomical space with
Surgery, Brigham and Womens
intracompartmental pressure causing a decrease of low compliance. Hospital, Harvard Medical
perfusion pressure, leading to hypoxaemia of the tissues. Acute extremity compartment syndromes can generally School, Boston, MA, USA
Decreased tissue perfusion can lead to irreversible necrosis be classied as primary (direct limb-related injury) or (M J Weaver, G S M Dyer,
Prof M S Vrahas); Department
that might result in functional impairment, loss of limb, secondary (non-limb-related injury). Medical management
of Orthopedic Surgery, Boston
and, in rare cases, death. Acute extremity compartment of underlying causes of secondary acute extremity Childrens Hospital, Harvard
syndrome is most frequently seen after a traumatic event, compartment syndrome with adequate crystalloid-sparing Medical School, Boston, MA,
but in up to 30% of cases occurs without any evidence of resuscitation, haemorrhage control, or both, might be USA (D S Bae); and Department
of Orthopedic Surgery, Beth
fracture.2,3 Other disorders that can cause acute extremity crucial in preventing its development. Primary and
Israel Deaconess Hospital,
compartment syndrome are thermal injuries (especially secondary causes aect hydrostatic pressure within a Harvard Medical School,
when circumferential), lithotomy positioning during compartment (gure 1) and are frequently seen in Boston, MA, USA (P T Appelton)
surgery, or constricting casts or wraps. Acute extremity combination. Correspondence to:
compartment syndrome has also been documented in Dr Arvind G von Keudell,
Orthopedic Trauma Initiative at
association with nephrotic syndrome,4 rhabdomyolysis,5
Harvard Medical School, Boston,
bleeding disorders,6 and iatrogenic factors, such as Search strategy and selection criteria
MA 02114, USA
accidental pressurised intravenous or extravenous infusion We searched PubMed, Embase, and Cochrane Library for avonkeudell@mgh.harvard.
of an agent.7 Furthermore, infections, especially with articles published within the previous 10 years. We used the
edu
Streptococcus spp, can cause acute extremity compartment search terms acute compartment syndrome and
syndrome.8,9 Therefore, almost any physician could see a fasciotomy plus optional terms treatment outcome,
patient with acute extremity compartment syndrome.1013 delayed diagnosis, and pathophysiology. Reports
Treatment with fasciotomy is well accepted, but delays providing high-level evidence were preferably selected.
in surgical or non-surgical treatment can result in Dependent on the number of results retrieved from each
permanent disability. All health-care professionals must, database, the respective search strategy was modied to
therefore, be familiar with the current standard of include more terms to narrow or broaden the desired
diagnosis and principles of the treatment of acute results. We reviewed article titles and abstracts for
extremity compartment syndrome.14 relevance, and manually searched the reference lists of
selected articles to identify commonly referenced and
Pathophysiology seminal older articles. Comments from peer reviewers of
The major muscle groups and neurovascular structures the report were also considered in the selection of
in the extremities are separated into compartments by relevant articles.
dense connective tissue called fascia. The biomechanical
Tissue trauma
Hypoperfusion/hypoxia
Intracompartmental bleeding
Intracompartmental pressure
Ischaemia
Venous capillary pressure
Development of
interstitial oedema Perfusion pressure
Constrictive Cellular
material necrosis
(eg, cast)
Reabsorption
Permeability
Development of interstitial oedema
Filtration
Reabsorption Lymph
P
Pressure
Intrinsic causes of acute extremity compartment The combination of hypoxia, increase in oxidant stress,
syndrome are tissue injury caused by a direct traumatic and development of hypoglycaemia in tissue cause cell
event or tissue ischaemia and reperfusion.17 Group A oedema due to a shortage of ATP and shutdown of the
streptococcal infections can be another cause, although the sodiumpotassium ATPase channels that maintain
mechanisms are not fully understood. Local swelling due physiological cellular osmotic balance. The subsequent
to pyrogenic exotoxin that functions as a super antigen is loss of cell-membrane potential results in an inux of
thought to lead to direct muscle injury.9 Precapillary chloride ions, which leads to cellular swelling and cellular
vasodilation in the arteriole system caused by muscle necrosis (gure 2). The resulting increase in tissue
injury, along with collapsing venules and increased swelling further worsens the hypoxic state and creates a
permeability of the capillary bed, leads to increased net positive feedback loop.
ltration and raised interstitial uid pressure in traumatised Another cause of acute extremity compartment
tissues. Interstitial uid pressure is normally lower than syndrome and compromised function is reperfusion
10 mm Hg. As it increases, adequate perfusion to tissue injury. Once vascularity is restored after an extended
becomes decreased. Once perfusion reaches pressure a period of ischaemia, the production of oxygen radicals,
critically low level, tissue hypoxaemia ensues (gure 1). lipid peroxidation, and calcium inux leads to
Na+/K+ ATPase
pump
02 deficiency/hypoxia
x
Acidosis and
inflammation
Damage to cell membrane Glycolysis
Na+ K+
H+
Anaerobic respiration Aerobic respiration
Loss of
membrane
potential
Lactic acid CI CI
0
0 Oxidants
02 Development of ATP
oxygen radicals
lipid peroxidation Swelling
Destruction of cell membrane
Na+
CI
disturbances of mitochondrial oxidative phosphorylation foot drop might develop.23,24 In the forearm, Volkmanns
and, ultimately, cell-membrane destruction. The sub- contracture is a possible complication where muscle
sequent release of hyperkalaemic and acidic blood brosis leads to decreased hand and wrist motion,
might also lead to kidney failure, cardiac arrhythmias, diminished strength, and clawing of the ngers.25
and, in severe cases, multiple organ damage that could
cause death.18,19 Diagnosis
The time from the initiating event to acute extremity Acute extremity compartment syndrome can be
compartment syndrome can vary from minutes to hours. diagnosed on the basis of clinical symptoms, intra-
Total ischaemia time and reduction of aerobic metabolism compartmental pressure, or both.
correlate with irreversible changes in various tissue types.
Peripheral nerve tissue is aected early in acute extremity History and clinical symptoms
compartment syndrome. Ischaemia of 1 h can lead to Some of the rst clinical signs that should raise the
reversible neurapraxia, and irreversible axonotmesis has suspicion of acute extremity compartment syndrome are
been suggested to occur as early as 4 h.20 When ischaemia severe pain out of proportion to the known injury, and
due to acute extremity compartment syndrome persists pain that does not improve with adequate analgesia.
for more than 6 h, irreversible changes are likely to occur,21 Resting pain and pain on passive stretching of the
initiating an irreversible, inammatory cascade that aected muscles might be seen. The signs and symptoms
results in brosis in necrotic muscle tissue, which causes of acute extremity compartment syndrome generally
further functional impairments, such as contractures.22 evolve progressively and, therefore, the diagnosis is
The clinical sequelae of untreated acute extremity usually made over a period of time unless it is strongly
compartment syndrome depend on the anatomical suspected at the initial presentation.26
compartment aected. In the leg, the anterior and Paraesthesia in the aected extremity might be one of
lateral compartments are most frequently aected and, if the rst signs of hypoxia to nerve tissue within a
untreated, ankle and foot contractures, dysaesthesias in compartment. For example, altered sensation in between
the deep and supercial peroneal nerve distributions, and the rst two toes could indicate deep peroneal nerve
ischaemia resulting from acute extremity compartment perfusion pressure is reached well before the systolic
syndrome in the anterior compartment of the leg. blood pressure, which leads to tissue ischaemia. Blood
Similarly, paresis of the extensor hallucis longus could ow through large arteries is preserved. Distal pulses
result from sustained ischaemia to the deep peroneal might not be aected at all or only when the compartment
nerve. However, clinicians must be very careful not to pressure rises above systolic blood pressure. At that
rule out compartment syndrome on the basis of absent stage, irreversible muscle damage is likely to have already
neurological signs; motor nerves have some resistance to occurred. Therefore, use of pulselessness as a primary
ischaemia, and objective motor decits might develop sign to assess compartment syndrome can cause delays
late. Moreover, patients who have had extremity trauma in diagnosis.
can be dicult to examine clinically, and anxiety, other In children, who are not small adults, some of the
distracting injuries, and altered mental status might clinical features discussed might not be applicable.
impede assessment. Children who cannot provide clear verbal expression of
Fullness or distension of the aected compartment symptoms might show signs of agitation, anxiety, and
should alert clinicians to the risk of acute extremity continually increasing need for analgesic pain medication
compartment syndrome. Subjective assessments of (the three As).31
compartments deemed tense or distended, however, are
unreliable even when judged by clinicians experienced Measurement of pressure
in trauma care and, therefore, are insucient to make If the clinical diagnosis is equivocal, measurement of
a diagnosis.27 intracompartmental tissue pressure might help to make
The commonly accepted clinical signs of acute the dierential diagnosis.32 The physiological compartment
extremity compartment syndrome, pain, pain on passive pressures in adults are around 8 mm Hg and in children
stretch, paraesthesia, and paresis, were shown in a are 1015 mm Hg.32,33
systematic review to have low sensitivity but high Several techniques have been used to obtain absolute
specicity for diagnosis, giving them poor predictive pressure values.21,26,34,35 Of these, arterial line transducer
value.28 A combination of three or more of these clinical systems with side-port needles, slit catheters, and self-
ndings in a patient at risk of acute extremity contained measuring systems are the most accurate.36,37
compartment syndrome might increase the sensitivity. Due to dierences in pressures within compartments,38,39
Of note, though, muscle paresis alone might be a late intracompartmental measurements should be obtained
sign of acute extremity compartment syndrome. roughly within 5 cm of the site of fracture.
The diagnosis is further complicated when there are Pressure measurements should be obtained in all
communication barriers between clinical sta and compartments of the extremities involved to avoid
patients, the patient has impaired awareness, or when missing the development of acute extremity compartment
patient-controlled analgesia, regional anaesthesia, or syndrome in a neighbouring compartment. The anterior
epidural pain catheters are used. Epidural pain catheters in compartment is the most common site for acute
particular carry important risks for masking compartment extremity compartment syndrome in the calf, followed
syndrome and should be avoided in high-risk patients.29 by the lateral compartment. Measurement of all
We emphasise that the use of the ve P mnemomic compartments in the distal aspects of the extremities,
(pallor, pain out of proportion, pulselessness, paraesthesia, such as the hand and the foot, should also be attempted,
and paralysis) to assess compartment syndrome is being vigilant of the high number of compartments.
misleading. These signs are more often signs of arterial Local anaesthesia or even conscious sedation might be
ischaemia than acute extremity compartment syndrome. helpful when measuring pressure in adults and children.
Instead, if the patient is awake, the ve Ps to consider Absolute pressure greater than 30 mm Hg is thought
are pain, pain, pain, pain, and pain. Acute extremity to be an indication of impaired tissue perfusion in adults
compartment syndrome should be at the top of the list of and children and, therefore, of the need for emergency
dierential diagnoses for any patient with excessive limb surgical fasciotomy.40,41 The use of an absolute value,
pain; pain and paraesthesia are frequently seen in patients however, has been questioned because the perfusion
presenting with acute extremity compartment syndrome, pressure necessary for oxygenation is partly dependent
but pallor, paralysis, and pulselessness might not on the patients blood pressure40,42,43 and, therefore, could
be present at all or could be very late signs. Rarely, lead to unnecessary fasciotomies. Some researchers have
compartment syndrome has been reported in awake and suggested the use of dierential pressure (p=diastolic
alert patients without severe pain.30 Therefore, it is blood pressure intracompartmental pressure), with a
important to maintain suspicion of acute extremity proposed threshold of 30 mm Hg.43 McQueen and
compartment syndrome in high-risk patients even when Court-Brown26 were among the rst to question absolute
they do not report excessive pain. cuto values. They assessed 116 patients with diaphyseal
The initial insult in compartment syndrome results tibia fractures by use of continuous measurement of
in impaired venous outow. As the pressure within intracompartmental pressure and found that the absolute
an anatomical compartment increases, the capillary intracompartmental pressure was more than 30 mm Hg
in 53 (46%) patients, more than 40 mm Hg in 30 (26%), some evidence from animal and basic science studies
and more than 50 mm Hg in four (3%). Only three support positive ndings,59,60 but its broader clinical
patients, however, had dierential pressures less than applicability has yet to be assessed in large trials.61
30 mm Hg and underwent emergency fasciotomy. No
patients had sequelae associated with acute extremity Specic compartment syndromes
compartment syndrome. A subsequent prospective study Patients who are at risk of developing acute extremity
of 101 patients by the same group conrmed that p had compartment syndrome must be identied promptly.
more diagnostic value than absolute intracompartmental The incidence of acute extremity compartment
pressure.44 Animal studies of intracompartmental syndrome is reported to be 73 per 100 000 of the general
pressure measurements support avoidance of absolute population for men and 07 per 100 000 for women.3 A
values to indicate compartment release. The data also large single-centre study in a level 1 trauma centre
suggest that irreversible tissue necrosis correlates directly showed that acute extremity compartment syndrome is
with the dierence between intracompartmental and associated with fractures of the tibial shaft in up to 36%
perfusion pressures over time.38,45 of cases.3 Other associated causes are soft-tissue injuries
Rates of diagnosis of acute extremity compartment of the extremities, distal radius fractures, crush injuries,
syndrome and emergency fasciotomy vary substantially. diaphyseal fractures of the radius and ulna, femoral
Some centres use continuous pressure monitoring to fractures, and tibial plateau fractures (table).3 In up to
assess all high-risk patients,26 whereas others rely on 30% of cases, however, acute extremity compartment
repeated clinical assessments of awake and coherent syndrome develops from soft-tissue injury without
patients.46 Intracompartmental pressure during surgery a fracture.2
might be reduced due to transient diastolic hypotension
associated with anaesthesia.47 Therefore, measurements Lower extremities
should be repeated after surgery to conrm complete The calf
release. The lower leg consists of four compartments: anterior,
Continuous measurement of intracompartmental lateral, supercial posterior, and deep posterior (gure 3).
pressure can be made by attaching a catheter to an The anterior intermuscular septum separates the lateral
arterial transducer. Although the technical learning curve muscles from the anterior muscles, and the posterior
for this approach is slightly greater than that for other intermuscular septum separates the lateral muscles from
methods, it might reduce the risk of missed compartment the posterior muscles. The interosseous membrane spans
syndrome.26,4850 Continuous measurement might be the gap between the tibia and bula, separating the
particularly benecial in patients with impaired aware- anterior and deep posterior compartments. The transverse
ness or consciousness in whom physical examination is intermuscular septum separates the musculature of the
not possible or in those who cannot report symptoms of supercial and deep posterior compartments.
pain and paraesthesia.51 Some studies, however, have The lower leg is the most common location of acute
suggest that the use of continuous measurement can extremity compartment syndrome, with the anterior
lead to unnecessary fasciotomy,52 which carries its own and lateral compartments most frequently aected.
risks and complications,53 such as long-term hospital Diaphyseal fractures of the tibia are mostly commonly
stay, infection, delayed wound healing, and, potentially, associated with acute extremity compartment syndrome
delayed bone healing.54 of the lower leg. An open injury does not exclude the
Most studies of measurement of intracompartmental possibility of developing acute extremity compartment
pressure have been done in patients with compartment syndrome.62 High-energy tibial plateau fractures and
syndrome in the leg. The ndings have been extrapolated
to other extremities and to children, despite the variability
in diastolic blood pressures and anatomy.55 Proportion of cases (%)
Fracture
Diagnostic tools under investigation Tibial diaphyseal fracture 36%
Near-infrared spectroscopy has been introduced into Distal radius fracture 10%
clinical practice as a new tool to measure tissue Diaphyseal forearm fracture 8%
oxygenation, and follows the principles of pulse oximetry.56 Femoral diaphyseal fracture 3%
Human tissue oxygenation is assessed by comparing the Tibial plateau fracture 3%
concentrations of venous blood oxyhaemoglobin and Soft tissue
deoxyhaemoglobin to a depth of around 3 cm in soft Soft-tissue injury 23%
tissue.57 In theory, near-infrared spectroscopy can monitor Crush syndrome 8%
patients at risk of acute extremity compartment syndrome Other 9%
by indirectly measuring decreased tissue perfusion due
Table: Incidence of fractures and other disorders associated with acute
to raised intracompartmental pressures. Near-infrared
extremity compartment syndrome
spectroscopy has been studied in small case series58 and
the forearm or hand, therefore, will have severe inltrates, crush injuries, and tight casts.41,9496 A review
functional consequences. Diagnosis might be delayed in found no correlation between the time from diagnosis to
patients who are uncooperative or have impaired fasciotomy and nal functional outcomes.97
awareness, which could lead to debilitating functional Acute compartment syndrome in the foot is rare in
outcomes. Late sequelae range from skin changes to children.98 Silas and colleagues99 have reported outcomes
contractures, neurological decits, infection, amputation, in the largest series of children with acute compartment
or death. Similar to acute compartment syndrome in syndrome in the feet and found that it most commonly
the lower extremities, time to diagnosis is crucial. The occurs due to crush injuries or Lisfrancs fracture
optimum timing of fasciotomy is suggested to be within dislocations.
8 h of development of acute extremity compartment The most important point to remember is that
syndrome. Whether fasciotomy is useful 824 h after presentation of acute extremity compartment syndrome
onset has been questioned because muscle necrosis has in children diers from that in adults, particularly in
generally already occurred. Fasciotomy for delayed acute terms of increasing need for analgesia after fracture.
compartment syndrome of the upper extremity might With timely diagnosis and appropriate fasciotomy,
not improve outcomes and has been associated with however, children can regain function and have
the need for multiple surgical procedures to debride favourable outcomes. Thus, a high index of suspicion
non-viable muscle tissue.64,91 should be maintained to avoid missed diagnosis and
unfavourable outcomes.
Acute extremity compartment syndrome in children
The diagnosis of acute extremity compartment Missed compartment syndrome
syndrome in children is particularly dicult and is The optimum treatment of acute extremity compartment
often delayed because the classic signs commonly cited syndrome is emergency fasciotomy immediately after
in adults are not helpful in children.31 Escalating pain, diagnosis. Animal studies suggest that tissue necrosis
pain with passive stretch of aected muscles, and occurs within 612 h of onset of hypoxaemia.21,100 Thus,
diminished perfusion are not straightforward to better clinical outcomes have been reported when fascio-
characterise, particularly in acutely injured, non-verbal, tomy is performed within this timeframe.50,92,101103 However,
or developmentally delayed children. For this reason, since acute extremity compartment syndrome is an
clinical diagnosis of acute extremity compartment evolving disorder with intracompartmental pressure
syndrome in paediatric patients should be based on the varying throughout its course, the exact time of onset
three As: anxiety, agitation, and increasing analgesic can be dicult to dene. The time from admission has
requirement.31 been suggested as a surrogate start point as it is closest
Acute extremity compartment syndrome in children to the time of injury.26,48 In some studies, though,
develops most frequently in association with fractures, researchers have chosen not to include an exact time of
especially of the lower extremities.31 In a study of onset as it cannot be clinically established.51
212 children with open or closed tibial fractures, Shore Crush syndrome might lead to acute extremity
and colleagues92 showed that the incidence of acute compartment syndrome. Vigilant monitoring is needed
extremity compartment syndrome was 116%. The time to identify metabolic disturbances, such as shock in
to fasciotomy was delayed (longer than 12 h after injury) association with renal failure, in patients who have crush
in 110 (52%) patients, but, surprisingly, was not injuries to skeletal muscle to reduce the risk of
associated with signicantly worse outcomes than rhabdomyolysis, which might lead to acute extremity
earlier treatment. 195 (92%) patients regained preinjury compartment syndrome. Adequate medical resuscitation
functional levels, which suggests that children tolerate treatment is of the utmost importance to counteract
increased intracompartmental pressure for longer hypotension, hypocalcaemia, hyperkalaemia, acidosis,
periods of time than adults before tissue necrosis and renal failure, especially in patients at risk of
becomes irreversible. Flynn and colleagues93 assessed reperfusion syndrome.
42 children with acute traumatic compartment syndrome If irreversible muscle necrosis has occurred before
treated with fasciotomy and followed up for an average surgical release, patients are at risk of seeding of necrotic
of 1 year. Only two patients had permanent functional muscle carrying bacteria that could lead to systemic
impairment, and in both the time from injury to eects. If necrotic muscle becomes infected, repeated de-
fasciotomy exceeded 80 h. Flynn and colleagues bridement is needed, and amputation might be necessary
highlighted the subtleties of diagnosis in paediatric if the infection cannot be controlled. This complication,
patients and noted that presentation of compartment therefore, creates a clinical dilemma of whether or not
syndrome might be delayed. fasciotomy should be performed if time of onset of acute
The largest case series of acute compartment syndrome extremity compartment syndrome is unclear.
in the upper extremities of children identied Missed compartment syndrome might have legal
supracondylar humerus fractures as one of the most consequences. Bhattacharyya and Vrahas104 identied
frequently associated injuries, followed by intravenous several risk factors for unsuccessful defence against
Low clinical suspicion of ACES High clinical suspicion of ACES Call for surgical consultation
No evidence of ACES
Emergency fascia release
Contributors 21 Rorabeck CH, Clarke KM. The pathophysiology of the anterior tibial
AGvK and MSV planned the paper, and AGvK drafted the manuscript compartment syndrome: an experimental investigation. J Trauma
framework and wrote the abstract. MSV summarised the relevance of 1978; 18: 299304.
the research about present care and assessed the evidence and reviewed 22 Huard J, Li Y, Fu FH. Muscle injuries and repair: current trends in
the whole paper. MJW helped with writing and reviewing of the sections research. J Bone Joint Surg Am 2002; 84-A: 82232.
on pathophysiology, lower-extremity compartment syndrome, and 23 Vandervelpen G, Goris L, Broos PL, Rommens PM. Functional
missed compartment syndrome. GSMD wrote and reviewed the section sequelae in tibial shaft fractures with compartment syndrome
on upper-extremity compartment syndrome. PTA wrote the clinical following primary treatment with urgent fasciotomy.
diagnosis and future developments sections. DSB wrote the section on Acta Chir Belg 1992; 92: 23440 (in Dutch).
paediatric compartment syndrome. MH did the literature search, 24 Zwipp H. Reconstructive surgery of sequelae of compartment
assessed the evidence, analysed and interpreted the data and, reviewed syndrome of the lower leg and/or foot. Presentation of a new
the sections on pathophysiology and lower-extremity compartment classication. Unfallchirurg 2008; 111: 77682 (in German).
syndrome. JBJ reviewed the section on missed compartment syndrome 25 Mubarak SJ, Carroll NC. Volkmanns contracture in children:
aetiology and prevention. J Bone Joint Surg Br 1979; 61-B: 28593.
and assessed the evidence in the whole paper.
26 McQueen MM, Court-Brown CM. Compartment monitoring in
Declaration of interests tibial fractures. The pressure threshold for decompression.
We declare no competing interests. J Bone Joint Surg Br 1996; 78: 99104.
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