SUPPLEMENT ARTICLE

Predicting Acute Compartment Syndrome (PACS): The

Role of Continuous Monitoring
Andrew H. Schmidt, MD,* Michael J. Bosse, MD,† Katherine P. Frey, RN, MPH,‡
Robert V. O’Toole, MD,§ Daniel J. Stinner, MD,k¶ Daniel O. Scharfstein, ScD,**
Vadim Zipunnikov, PhD,** Ellen J. MacKenzie, PhD,‡ and METRC
Downloaded from https://journals.lww.com/jorthotrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3+5UxwP5IFlBD9KwJYCFGgxWp17zOrfICl/C95nwBsgc= on 05/20/2020

will improve our understanding of the natural history of compart-

Summary: The diagnosis of acute compartment syndrome (ACS)
is a common clinical challenge among patients who sustain high-
energy orthopaedic trauma, largely because no validated criteria
exist to reliably define the presence of the condition. In the absence
of validated diagnostic standards, concern for the potential clinical
and medicolegal impact of a missed compartment syndrome may
result in the potential overuse of fasciotomy in “at-risk” patients.
The goal of the Predicting Acute Compartment Syndrome Study
was to develop a decision rule for predicting the likelihood of ACS
that would reduce unnecessary fasciotomies while guarding against
potentially missed ACS. Of particular interest was the utility of
early and continuous monitoring of intramuscular pressure and
muscle oxygenation using near-infrared spectroscopy in the timely
diagnosis of ACS. In this observational study, 191 participants
aged 18–60 with high-energy tibia fractures were prospectively
enrolled and monitored for up to 72 hours after admission, then
followed for 6 months. Treating physicians were blinded to con-
tinuous pressure and oxygenation data. An expert panel of 9 ortho-
paedic surgeons retrospectively assessed the likelihood that each
patient developed ACS based on data collected on initial presenta-
tion, clinical course, and known functional outcome at 6 months.
This retrospectively assigned likelihood is modeled as a function of
clinical data typically available within 72 hours of admission
together with continuous pressure and oxygenation data. This study
Accepted for publication January 13, 2017.
From the *Department of Orthopaedic Surgery, Hennepin County Medical
Center, University of Minnesota, Minneapolis, MN; †Department of Ortho-
paedic Surgery, Carolinas Medical Center, Charlotte, NC; ‡Department of
Health Policy and Management, Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD; §R Adams Cowley Shock Trauma Center,
Department of Orthopaedics, University of Maryland School of Medicine,
Baltimore MD; kDepartment of Orthopaedics, San Antonio Military Med-
ical Center, US Army Institute of Surgical Research, San Antonio, TX;
¶Centre for Blast Injury Studies, Imperial College London, London, United
Kingdom; and **Department of Biostatistics, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD
A. H. Schmidt holds stock in Twin Star Medical and Twin Star ECS. The
remaining authors report no conflict of interest.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Web site (www.
jorthotrauma.com).
Clinicaltrials.gov #: NCT01561261. Department of Defense Contract #:
W81XWH-10-2-0090.
Reprints: Andrew H. Schmidt, MD, Hennepin County Medical Center, 701 Park
Avenue South, Minneapolis, MN 55415 (e-mail: schmi115@umn.edu).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000000796
ment syndrome and examine the utility of early and continuous
monitoring of the physiologic status of the injured extremity in
the timely diagnosis of ACS.
Key Words: acute compartment syndrome, oxygenation monitoring,
pressure monitoring, fasciotomy, near-infrared spectroscopy (NIRS)
(J Orthop Trauma 2017;31:S40–S47)
BACKGROUND AND RATIONALE
Acute compartment syndrome (ACS) occurs in as many
as 11%–18% of high-energy tibia fractures1,2 and remains
a diagnostic challenge, a source of morbidity for trauma pa-
tients, and adds significant costs to caring for the injured
patient.3–6 There are currently no validated clinical criteria
that reliably identify when ACS is present. Instead, clinicians
rule out ACS based on the absence of concerning clinical
findings and, in some cases, by demonstrating that tissue
perfusion pressure (PP) is “safe” (PP $30 mm Hg).1 How-
ever, for both clinical findings and isolated measurements of
intramuscular pressure (IMP) or PP, there are few prospective
clinical studies assessing their sensitivity or positive predic-
tive value, limiting the application of their use to reliably
diagnose ACS.7,8 What little data exist raises concerns for
the efficacy of these tests, both in the reliability of the test
itself,9 and the relationship between the results of the test and
the diagnosis of ACS.7,8,10
ACS remains a challenge to diagnose in patients with
extremity trauma, and because of the devastating nature of the
consequences of missed compartment syndrome, it is a com-
mon source of litigation in civilian practice.11 Patients with
concerning clinical findings and/or pressure measurements sus-
picious for ACS are treated with urgent surgical fasciotomy12
which immediately reduces IMP and restores myoneural per-
fusion.7 It is likely, however, that some patients undergoing
fasciotomy do not have compartment syndrome and are receiv-
ing unnecessary and markedly morbid surgery. Although fas-
ciotomies introduce complications and morbidity, the practice
is accepted because the morbidity of delayed fasciotomy or
missed diagnosis of ACS can be greater. Cases of ACS that
are not treated with timely fasciotomy are associated with mus-
cle necrosis, which in the short term may cause rhabdomyol-
ysis and renal failure, and in the long term may result in
ischemic contracture of the involved compartment and perma-
nent functional deficit.13 In 2 series of patients, delayed and

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J Orthop Trauma  Volume 31, Number 4 Supplement, April 2017
incomplete fasciotomy were associated with increased morbid-
ity and mortality, and a high rate of limb amputation.14,15
Because the current management of ACS is based on
subjective clinical assessments, it is not surprising that the
rate of fasciotomy varies significantly among clinicians.10
Less often discussed is the fact that all research published
to date on ACS is affected by the lack of a strict gold stan-
dard for diagnosis. Lacking such a standard, the perfor-
mance of fasciotomy has been used in past studies as
a proxy for the presence of ACS, where patients who
undergo fasciotomy are considered to have had ACS,
despite the fact that an unknown proportion of them did
not actually have the condition. This lack of a strict defini-
tion of ACS compromises understanding of the condition,
including its diagnosis and treatment. The development of
a decision rule for ACS could by itself reduce the incidence
of fasciotomy simply by lessening the number of false-
positive diagnoses. It would also guard against the potential
for a missed (or delayed) diagnosis of ACS. Such a decision
rule would also facilitate further research on potential ther-
apies for ACS by providing a set of standardized criteria for
the diagnosis of ACS.
No one has carefully mapped the relationship between
clinical signs, objective, continuous measurements of leg
perfusion or IMP and a diagnosis of ACS. Continuous
pressure monitoring has been shown to have high sensitivity
and positive predictive value in 1 retrospective study,1 but
this technique is not commonly used in North America.
Recently, a noninvasive means of monitoring skeletal muscle
perfusion with near-infrared spectroscopy (NIRS) became
available, and its potential role in the diagnosis of ACS has
been reported.16–21 It is hypothesized that monitoring skeletal
muscle perfusion in a continuous fashion could greatly assist
clinicians in making a timely and accurate diagnosis of ACS,
so that early fasciotomy can be performed and unnecessary
fasciotomy avoided. However, NIRS has not been widely
studied in ACS, and combined monitoring using both NIRS
and continuous pressure monitoring has not been reported,
despite the potential value of these complementary
technologies.
The Predicting Acute Compartment Syndrome Study
was designed to develop a better understanding of the natural
history of elevated compartment pressure and the utility of
early and continuous monitoring of the physiologic status of
the injured extremity in the timely diagnosis of ACS. In this
study, the probability of ACS is determined retrospectively by
an independent panel of experts based on the patient’s initial
presentation, clinical course, and known outcome at 6 months
(including functional outcome and presence or absence of
myoneural deficit). These probabilities are then modeled as
a function of the clinical information obtained within the first
72 hours of injury to determine the predictive value of the
data that would be available at the time of initial assessment.
The immediate objective of the study is the development of
a model that accurately predicts the likelihood of ACS based
on data available to the clinician within the first 72 hours of
injury, to include specific clinical findings supplemented by
objective data obtained from state-of-the-art physiologic mon-
itoring tools, specifically, muscle oxygenation measured
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Predicting Acute Compartment Syndrome
using NIRS, and continuous monitoring of IMP and PP.
The long-term objective of the research is to develop a tool
that can aid clinicians in making a timely and accurate diag-
nosis of ACS.
METHODS: STUDY PROCEDURES AND
PATIENT SELECTION
Overview
The study was conducted at 7 US trauma centers
participating in the Major Extremity Research Consortium
(METRC), which are listed in the Appendix 1.22 All study
materials, including the protocol, consent, and recruitment
materials, were developed in conjunction with the METRC
Coordinating Center located at the Johns Hopkins Bloomberg
School of Public Health and approved by the Department of
Defense (DoD) Human Research Protection Office (study
sponsor) and the local institutional review board (IRB) at each
participating center. Local sites also obtained DoD Human
Research Protection Office approval of local IRB documents
and were thoroughly trained and then certified by the Coor-
dinating Center before engaging in study activities to ensure
proper execution of study procedures and data collection.
In this prospective study, no intervention was used to
alter the treating physician’s standard of care for the diagnosis
or treatment of ACS. Physicians were blinded to continuous
oxygenation and pressure data.
Patient Selection Criteria and Consent
The study inclusion and exclusion criteria are outlined
in Table 1. Patients meeting the study inclusion criteria were
approached for informed consent within 18 hours of injury.
Legally authorized representatives were approached when pa-
tients were unable to provide informed consent. METRC has
adopted a comprehensive informed consent process for all of
its studies that involves the treating surgeon, the clinical site
research coordinator, and material and resources for patients
and family members to facilitate informed decision making
about participation (see Figure, Supplemental Digital Con-
tent Figure 1, http://links.lww.com/BOT/A898 describes the
METRC consenting procedures).
Study Procedures: In-Hospital Monitoring
After obtaining informed consent, 48 hours of moni-
toring was initiated. This monitoring included blood pressure,
pain (using a visual analog scale23), neurovascular assess-
ments including assessment of pulses, pain with passive
stretch, muscle strength, and a sensory examination of the
superficial peroneal, deep peroneal, sural, and posterior tibial
nerves of the injured limb every 4 hours. Also obtained were
daily creatinine phosphokinase values and continuous IMP
monitoring and tissue oxygenation monitoring. The study
injury was characterized using the AO/OTA fracture classifi-
cation,24 Gustilo classification,25 and Tscherne soft tissue
classification.26 Standard of care radiographic images were
captured in the study database. All participants who under-
went a surgical procedure to the study the limb during the
initial monitoring interval were disconnected from monitors
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Schmidt et al J Orthop Trauma  Volume 31, Number 4 Supplement, April 2017

in this study. Tissue oxygenation was monitored using the

TABLE 1. Inclusion and Exclusion Criteria for the Predicting
Nonin Medical Equanox 7600 (Plymouth, MN) with the
Acute Compartment Syndrome Study
8003CA sensor. Both devices are cleared by the FDA for
Inclusion Criteria Exclusion Criteria the study procedures; a nonsignificant risk determination
1. Ages 18 and 60 who presented 1. Soft tissue wounds interfered with was obtained to allow the PMFC catheters to be used for
within 18 h of injury monitoring (ie, the insertion of up to 48 continuous hours, as they are only FDA approved
2. Injury associated with a high indwelling pressure catheters and/
risk of ACS including, but not or application of spectroscopy for 24 hours.
limited to sensors) Continuous monitoring of both pressure and oxygena-
Closed tibial shaft fracture 2. Informed consent from the patient tion was done only in the anterior compartment, according to
occurring in the proximal half of or from a legally authorized the “sentinel compartment” principle, which relates to the fact
the tibia with displacement, representative was not obtained
comminution, or segmental early enough to begin monitoring
that the anterior compartment typically is the earliest com-
pattern within 18 h postinjury partment involved in ACS and usually has the highest pres-
Closed bicondylar tibial plateau 3. Medical history significant for sures.6,27 In addition, the deep posterior IMP was monitored
fracture or medial tibial plateau peripheral vascular disease with a pressure catheter because this compartment is also
fracture or knee fracture- 4. Prior extensive traumatic injury commonly involved and is the most difficult compartment
dislocation requiring surgery to either lower
Open tibial shaft fracture (Gustilo extremity to monitor clinically.
type I, II, or III A) occurring in the 5. Non-ambulatory due to an In this study, treating physicians were blinded to the
proximal half of the tibia associated complete spinal cord NIRS and continuous measures of IMP and PP, and their
Open bicondylar tibial plateau injury diagnosis and treatment of ACS followed standard practice.
fracture or medial tibial plateau- 6. Non-ambulatory before the injury
knee dislocation (Gustilo type I, due to a pre-existing condition
Specifically, clinicians monitored the patient using standard
II, or III A) 7. Unable to speak either English or clinical guidelines, and had the ability to use the IMP monitor
Severe soft tissue crush injury to Spanish; or to obtain up to 2 discreet measures of IMP if and when they
proximal half of the tibia 8. Severe problems with maintaining determined that pressure measurement was clinically indi-
High-energy gunshot injury to follow-up cated as part of their standard management of patients at risk
leg, with significant soft tissue
swelling of ACS.
Tibia fracture resulting from Additional data were collected on subjects who
a sports-related injury, such as received a fasciotomy during the monitoring period, including
soccer or football prefasciotomy and postfasciotomy pressure (using a Stryker
3. Regardless of timing, any acute
onset of clinical symptoms
device), oxygenation (using the NIRS sensor), and clinical
consistent with the likelihood of data, including appearance of tissue at the time of fasciotomy,
compartment syndrome, including and time to and method of wound closure. Photographs of the
4. Visual analog scale pain score $7 wound were also obtained. No additional compartment
that is stable or worsens with monitoring was conducted after the fasciotomy.
serial examinations
5. Pain not controlled with narcotics
6. Pain with passive stretch of Study Procedures: Patient Follow-up
involved muscle compartment (if Participants were asked to return for follow-up study
possible to assess) visits at 3 and 6 months after injury. At the 3-month study
7. Measurement of IMP is indicated visit, the participants completed the Short Form Musculo-
to assist with interpretation of
clinical findings; or for a patient
skeletal Function Assessment (SMFA).28 At the 6-month
who was intubated and visit, participants completed the SMFA again, and muscle
unresponsive, increased swelling strength was assessed using a handheld dynamometer (Micro-
and increased clinical concern of FET2 MMT) and single leg heel rise tests.29 A clinical exam-
ACS, such that the clinicians have ination was conducted to assess the presence of myoneural
decided that IMP measurement is
indicated to assist with deficit (based on sensory and motor examination of superfi-
interpretation of clinical findings cial peroneal, deep peroneal, sural, posterior tibial nerves),
8. Patients’ weight .88 lbs complications, wound healing, and fracture healing (defined
9. Uninjured limb that could serve as as healed if no pain with weight-bearing, bridging callus on 3
a control cortices). Photographs were taken of the leg to include the
surgical incisions and/or wound site, and follow-up radio-
graphs were obtained. For patients who did not return to
clinic, a combination of chart review and phone calls was
during the procedure. After the procedure, monitoring used to assess gross myoneural function, including use of
resumed for an additional 24 hours. a device or orthotic to assist in ambulation, and pain.
Continuous IMP was assessed using the Twin Star
ECS (Bloomington, MN) Pressure Monitoring Fluid Col- Protocol Changes
lection (PMFC) catheter and ECS monitoring unit, which The protocol underwent several modifications, most
recorded IMP and the patient’s blood pressure. The PMFC of which were administrative in nature. Most significantly,
catheters were not connected to suction, and only the pres- after 100 patients were enrolled, the protocol was amended
sure monitoring functionality of the devices was employed to limit enrollment to participants at a higher suspected risk

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J Orthop Trauma  Volume 31, Number 4 Supplement, April 2017 Predicting Acute Compartment Syndrome

FIGURE 1. Representative continuous

muscle oxygenation and compartment
pressure data. The first 2 plots corre-
spond to oxygenation data received
from the anterior compartment of the
injured and control limb, respectively.
The third plot is a ratio of the oxygen-
ation data from injured limb to the
control limb. The fourth and fifth plots
correspond to pressure data recorded
from the anterior and deep posterior
compartments of the injured limb,
respectively, and the dots represent
diastolic blood pressure (recorded once
every 4 hours). The bars denote time in
the operating room.

of ACS and to expand the window for enrollment from 12 initial barrier to enrollment and allowed a focus on
to 18 hours postinjury. Specifically, patients with distal enrolling the individuals most likely to develop the out-
tibia fractures were excluded. These changes overcame an come of interest.

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Schmidt et al
METHODS: ASSIGNING PROBABILITY OF ACS
Once collected, data were cleaned and displayed on
a custom online application designed for this study to present
the data in a 2-stage process to allow reviewers to assess the
likelihood that each participant had experienced a compart-
ment syndrome based first on clinical data typically available
(injury characteristics, radiographs, pain medications admin-
istered, neurovascular assessment data, surgical procedures,
and myoneural and functional outcomes), and then with the
addition of continuous oxygenation and pressure monitoring
data (Fig. 1). Nine clinical experts, grouped in 3 panels of 3,
were asked specifically to (1) estimate the likelihood that the
person had compartment syndrome (0–100 scale, where 50 =
completely unsure); (2) identify the 3 most important aspects
contributing to that decision; (3) indicate whether or not they
thought the patient had compromised muscle perfusion that
would have benefited from a fasciotomy; (4) indicate whether
they would have performed a fasciotomy if they had been the
clinician responsible for the care the patient; and (5) indicate
whether or not the pressure and/or oxygenation data influ-
enced decision making, for the second round of scoring.
Finally, reviewers were asked to identify whether or not data
were missing that would have influenced decision making,
and if so, what the impact would have been. Each panel
reviewed 25% of the cases, and all 9 experts reviewed the
remaining 25% of cases to allow for calibration of ratings
across panels. When a panel was discordant in their assess-
ment of likelihood of ACS (defined as a range of scores
.30%), the group was brought together to review the case,
and the case was rescored by all 9 experts. The goal of
rescoring was not to force consensus but rather to allow
reviewers to discuss aspects of the case that influenced
FIGURE 2. Predicting Acute Com-
partment Syndrome Study enroll-
ment summary.
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J Orthop Trauma  Volume 31, Number 4 Supplement, April 2017
decision making and prevent a single score from unduly influ-
encing results.
METHODS: DATA MANAGEMENT, SAMPLE
SIZE, AND ANALYSIS
Data Management
Data were collected by site research coordinators and
clinical investigators using paper case report forms designed
specifically for this study and then entered into REDCap,30
the web-based data collection system used in all METRC
studies. Monitoring data were downloaded from the devices
and uploaded to REDCap (see Figure, Supplemental Digital
Content Figure 2, http://links.lww.com/BOT/A899).
Sample Size
The sample size was determined using a simulation
study. Various sample sizes, ranging from 100 to 1000, were
considered. For each proposed sample size, oxygenation and
pressure levels at 2 time points were generated for each
patient, and, based on these levels, an average probability of
ACS (as would be assigned by the expert panel) was
generated. A regression based on these data was then built
and evaluated for its predictive ability on a hypothetical
external validation dataset of 2000 patients. There was an 8%
improvement in predictive ability when increasing the sample
size from 100 to 200, a 2% improvement between 200 and
300, and even smaller percentage improvements for larger
sample sizes. With these results, the study was designed to
enroll 200 patients.
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J Orthop Trauma  Volume 31, Number 4 Supplement, April 2017 Predicting Acute Compartment Syndrome

TABLE 2. Baseline Characteristics: Patient and Injury TABLE 2. (Continued ) Baseline Characteristics: Patient and
All Patients (n = 191) Injury
Age All Patients (n = 191)
Mean (SD), n (%) 38 (12.7) Very good 80 (42)
,25 37 (19) Good 49 (26)
25–34 45 (24) Fair or poor 14 (7)
35–44 41 (21) Missing 1 (1)
45–54 45 (24) Fracture classification, n (%)
.54 23 (12) Closed fractures 95 (50)
Sex, n (%) Tscherne grade C0 20 (10)
Male 143 (75) Tscherne grade C1 60 (31)
Race-ethnicity, n (%) Tscherne grade C2 10 (5)
Hispanic 19 (10) Tscherne grade C3 5 (3)
Non-Hispanic non-white 46 (24) Open 96 (50)
Non-Hispanic white 124 (65) Gustilo type I 19 (10)
Other 2 (1) Gustilo type II 30 (16)
Health insurance, n (%) Gustilo type III A 47 (25)
No insurance 50 (26) OTA classification, n (%)
Medicaid 19 (10) 41 (proximal tibia) 63 (33)
Private 74 (39) 42 (tibia shaft) 123 (64)
Other 41 (21) 43 or 44 (distal tibia or malleolus) 5 (3)
Unknown 7 (4) Mean monitoring time (SD), hr 37.4 (16)
Body mass index (BMI) Mean length of stay (SD), d 9.7 (9.7)
Mean (SD), n (%) 29.1 (7.1) Mean number of surgeries (SD) 1.8 (1.9)
,25 61 (32)
25–30 56 (29)
30–35 35 (18) Analysis
$35 39 (20) The time series of pressure and oxygenation will be
Mechanism, n (%) summarized based on both clinical and data-driven criteria.
Motor vehicle-occupant 54 (28) The outcome of the panelists’ reviews will be modeled using
Motor vehicle-cyclist or pedestrian 43 (23) generalized mixed effects models with linear31 and regression
Motor vehicle-motorcyclist 42 (22) tree structures.32 These models will include random effects to
Fall from standing 9 (5) account for the fact that each patient has multiple raters, and
Fall from height .10 ft 10 (5) each rater is evaluating multiple patients. “Optimal” predic-
Firearm 5 (3) tion models will be developed based on (1) only clinical
Other mechanism 28 (15) variables that are available before making the decision to
Tobacco use, n (%) perform a fasciotomy and (2) these variables plus the sum-
Current tobacco use 77 (40) maries of pressure and oxygenation. The “value-added” of the
Former tobacco use 29 (15) models which include pressure and oxygenation data will be
No tobacco use 82 (43) formally evaluated. The models will be developed using
Refused/unknown/missing 3 (2) cross-validation techniques. Other prediction approaches
Usual major activity preinjury, n (%) (eg, random forests, bagging, and boosting32) will be inves-
Working/active duty 138 (72) tigated. Multiple imputation methods will be used to handle
Laid off/looking for work 17 (9) missing data.33–35
Going to school 9 (5)
Taking care of your house 15 (8)
Something else 11 (6) STUDY ENROLLMENT AND BASELINE DATA
Missing 1 (1) In total, 191 participants from 7 centers were enrolled in
Major comorbidity preinjury (count), this study (32% of those eligible); 48% of eligible patients
n (%) were not enrolled because of administrative reasons, primarily
0 113 (59) related to lack of availability of equipment or staff to enroll
1 56 (29) a participant within the 18 hours window (Fig. 2). Final out-
$2 22 (12) comes were obtained on 181 (95%) participants, 163 (85%) of
Self-assessed health status preinjury, which were completed in person. Participants were monitored
n (%)
for an average of 37.4 hours (SD 16 hours), and 24 (12.6%)
Excellent 47 (25)
received a fasciotomy. The average age was 38.1 years (SD
12.8). The study sample was 75% male, most of injuries were
motor vehicle-related (28% occupant, 22% pedestrian or

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Schmidt et al
cyclist, and 22% motorcyclist). Nearly one half (49%) of
participants overall had a closed fracture. Patient character-
istics are summarized in Table 2.
DISCUSSION
This study has many strengths. The prospective collec-
tion of clinical signs (pain, motor strength, sensation)
provides more reliable information than can be obtained from
retrospective chart review. Furthermore, the continuous
monitoring of both IMP and oxygenation using NIRS will
provide new information for clinicians to consider regarding
the utility of these tests in predicting the likelihood of ACS.
Most importantly, the blinded collection of these continuous
assessments affords the opportunity to examine the utility of
these measures without influencing actual clinical decisions
regarding whether or when to perform fasciotomy.
An additional strength of the study is that it addresses
one of the most significant challenges in compartment
syndrome research. Although there are proposed indicators
for when to perform fasciotomy,1,5,27 there are no validated
gold-standard definitions that reliably indicate when ACS is
either present or an imminent diagnosis. Lacking such a stan-
dard, the performance of fasciotomy has been typically con-
sidered synonymous with the diagnosis of compartment
syndrome. In this study, the predictive value of the various
types of clinical data that are available after injury will not be
determined until there has been an independent assessment by
a panel of experts as to whether the patient actually had
a compartment syndrome, based not only on the patient’s
initial presentation and clinical course, but also on the known
outcome data for each patient.
Although the predictive value of clinical findings,8 dis-
crete IMP measurements,7,9 and continuous pressure monitor-
ing1 have been evaluated independently, no study has yet
evaluated the reliability of NIRS for diagnosis of ACS, and
no study has combined these assessments together into a sin-
gle clinical decision rule. In addition, the consensus panels are
directed to distinguish between cases where they believe there
was compromised muscle perfusion that would have
benefited from a fasciotomy versus cases where a “prophylac-
tic” fasciotomy was conducted based on the risk of compart-
ment syndrome developing in the future. This will allow some
investigation of any remaining gaps in the assessment of
compartment syndrome and provide some insight into clinical
decision making.
One of the main weaknesses of this study is the lower-
than-expected incidence of fasciotomy. Midway through the
study, the study inclusion criteria were modified, with a goal
of increasing the percentage of cases receiving fasciotomy
(and by proxy, increasing the number of likely compartment
syndrome cases) in the study. Although this increased the
number of fasciotomies, overall fasciotomy rate remained low
(12.6%).
Although the prediction model to be developed as part
of this study will require validation in an independent sample
of patients, it has the potential to define a diagnostic standard
for the treatment of compartment syndrome, both in civilian
practice and in the treatment of patients with military
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J Orthop Trauma  Volume 31, Number 4 Supplement, April 2017
orthopedic injuries. The long-term goal of this research is to
integrate the classic clinical signs and symptoms of ACS
(which by themselves are of uncertain clinical significance)
with the latest advances in monitoring and treatment of ACS:
NIRS and continuous monitoring of IMP. The long-term goal
of deriving a validated prediction rule tool for ACS will
benefit patients and surgeons by reducing the incidence of
both unnecessary fasciotomy and missed ACS. Furthermore,
the insights gained by evaluating both the usefulness of
various data points and the clinical decision-making process
with regard to diagnosing ACS and determining the need for
fasciotomy will inform further research that may in turn lead
to refinements in the clinical care of these complex patients.
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APPENDIX 1. CORPORATE AUTHORS
Participating Centers: Carolinas Medical Center:
Michael J. Bosse, MD, Christine Churchill, MA, Joseph R.
Hsu, MD, Rachel B. Seymour, PhD, Madhav A. Karunakar,
MD, Stephen H Sims, MD; Hennepin County Medical Cen-
ter: Andrew H. Schmidt, MD, Gudrun E Mirick, MD, Jerald
R. Westberg, BA; San Antonio Military Medical Center:
Daniel J. Stinner, MD; Denver Health Medical Center: David
J. Hak, MD, MBA, FACS; University of Maryland R Adams
Cowley Shock Trauma Center: Robert V. O’Toole, MD, The-
odore Manson, MD, Timothy G. Costales, MD, Amanda C.
Holmes, MS, Jason W. Nascone, MD, Andrew G. Dubina,
MD; Vanderbilt Medical Center: William T. Obremskey,
MD, MPH, MMHC, Eduardo J. Burgos, MD, A. Alex Jahan-
gir, MD, MMHC, Hassan R. Mir, MD, MBA, FACS (now at
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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ankle joint and a heel-raise test for endurance. Knee Surg Sports
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8:3–15.
University of South Florida Department of Orthopaedic
Surgery), Rajesh R. Tummuru, MBBS, Manish K. Sethi,
MD; Wake Forest Baptist Medical Center: Eben A. Carroll,
MD, J. Brett Goodman, MBA, Jason J. Halvorson, MD, Mar-
tha B. Holden, AAS, AA, Anna N. Miller, MD, FACS (now
at Washington University in St. Louis School of Medicine);
Other Corporate Authors: Brown University Warren Alpert
School of Medicine: Roman A. Hayda, MD (protocol com-
mittee member); METRC Coordinating Center at Johns
Hopkins Bloomberg School of Public Health: Ellen J.
MacKenzie, PhD, Lauren E. Allen, MA; Anthony R. Carlini,
MS, Renan C. Castillo, PhD, Susan Collins, MSc, Katherine
P. Frey, RN, MPH, Grace K. Ha, PhD, Daniel O. Scharfstein,
ScD, Vadim Zipunnikov, PhD.
www.jorthotrauma.com | S47