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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Acute Compartment Syndrome: Do guidelines for diagnosis and

management make a difference?
D. Bodanskya,* , A. Doorgakanta , J. Alsousoua,b , H.J. Iqbalc, B. Fischerc,e , G. Sciclunad ,
M. Bowersc , B. Narayana
a
Royal Liverpool University Hospital, United Kingdom
b
University of Liverpool, United Kingdom
c
Aintree University Hospital, United Kingdom
d
Royal Preston Hospital, United Kingdom
e
Salford Royal Hospital, United Kingdom

A R T I C L E I N F O A B S T R A C T

Background: The best outcomes following Acute Compartment Syndrome (ACS) are attributed to early
Keywords: diagnosis and treatment. National guidelines were issued in the United Kingdom in 2014 (BOAST 10) to
Acute compartment syndrome
standardise and improve management. We analysed standards of diagnosis and management before and
BOAST guidelines
Fasciotomy
after the introduction of the guidelines.
Methods: We retrospectively reviewed the data of all patients with ACS requiring fasciotomy between
March 2010 and May 2015 across four Major Trauma Centres (MTCs) in the Northwest of England. We
analysed the pooled data for variations between the centres and the effect of BOAST10 implementation.
Results: 75 fasciotomies were recorded, with trauma being the cause in 42 cases (56%). The commonest site
was the leg (44, 59%) followed by the forearm (15, 20%). The median time from decision to operate to
fasciotomy was 2 h (range 0–6) and thereafter a median of 2 days (1–7) until a second visit. The practice
across the four centres was similar up to diagnosis and treatment, but there was significant variation in
practice after fasciotomy. The BOAST guidelines did not improve the time to surgery, time to second visit nor
the recording of clinical signs. 21 patients had severe complications, including one death and 4 amputations.
Conclusions: There continues to be significant variability in the definitive management of ACS. National
guidelines do not appear to make a discernible impact on practice, and additional methods of ensuring safe
management of this critical condition seem warranted.
© 2018 Elsevier Ltd. All rights reserved.

Introduction
Acute compartment syndrome (ACS) is an uncommon but
serious condition associated with high morbidity and mortality
[1,2]. The literature about this topic is well established, but few
epidemiological studies exist [3–5].
In the United Kingdom, national guidelines on the management
of acute compartment syndrome of the limbs were published for
the first time by the Trauma Group of the British Orthopaedic
Association (BOAST 10) in May 2014 [6].
Our primary aim was to study the impact of the BOAST 10
guidelines on practice across 4 Major Trauma Centres (MTCs). We
chose to explore the impact of the recently introduced BOAST10
guidelines with respect to the following standards: Standard 3 “The
key clinical findings are pain out of proportion to the associated injury
and pain on passive movement of the muscles of the involved
compartments. Limb neurology and perfusion, including capillary
refill and distal pulses, should be clearly documented but do not
contribute to early diagnosis of the condition.”, Standard 7
“Compartment syndrome is a surgical emergency and surgery should
occur within an hour of the decision to operate” and Standard 12
“( . . . ) All patients should undergo re-exploration at approximately
48 hours, or earlier if clinically indicated ( . . . )
There is a perception that the aetiology of ACS is changing, with
an increased prevalence of non-traumatic causes. The secondary
aims were to look for variations in practice, and the aetiology of
ACS in a large geographic area, the North-West of England.
Methods

* Corresponding author.
We performed a retrospective cohort study of all patients with
E-mail address: david.bodansky@nhs.net (D. Bodansky). ACS admitted to the four Level 1 Major Trauma Centres (MTC) in

https://doi.org/10.1016/j.injury.2018.04.020
0020-1383/© 2018 Elsevier Ltd. All rights reserved.

Please cite this article in press as: D. Bodansky, et al., Acute Compartment Syndrome: Do guidelines for diagnosis and management make a
difference?, Injury (2018), https://doi.org/10.1016/j.injury.2018.04.020
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the North West of England (the Royal Liverpool University
Hospital, Aintree University Hospital, Royal Preston Hospital and
Salford Royal Hospital) at the time of the study. The catchment
area is of a population of about seven million. Six investigators
used a standardised data collection proforma across the four
hospitals. Electronic patient records were searched for ICD-10
codes for fasciotomies (T54 and T55) between 1st May 2010 and
1st May 2015 with individual case reviews to confirm the
indication was ACS. All patients who underwent an emergency
fasciotomy of a limb were included. Patients who had elective or
scheduled fasciotomies for chronic compartment syndrome were
excluded.
Data collected included patient demographics, cause of ACS,
site, documentation of diagnostic signs and symptoms, use of
adjuncts to measure compartment pressures,use of split skin
grafting, complications and timing of events: arrival to hospital;
diagnosis; fasciotomy (initial surgery); further theatre visitts and
final closure.
Data was analysed using SPSS statistics software version 24.0
(SPSS Inc., Chicago, Illinois). The majority of the data was non-
parametric, and non-parametric tests were used throughout the
study. The Kruskal-Wallis with Bonferroni correction for multiple
tests was used to analyse more than two groups and Mann
Whitney U test was used for two group analysis. The correlation
between timing and number of visits and final wound closure was
performed using Spearman rho test. A p-value <0.05 was deemed
significant.
Results
Seventy-five patients across the four centres were identified.
The demographics are presented in Table 1.
The aetiology and anatomical site of ACS are listed in Tables 2
and 3 respectively.
The causes in the non-traumatic other category were varied and
are listed below: 4 related to intravenous drug injection; 2
spontaneous haematomas in patients with no bleeding disorders
nor on anticoagulants; 2 lying unconscious from opiate overdose; 1
lying unconscious from alcohol abuse; 1 intravenous fluid
extravasation in a hand; 1 ruptured Baker’s cyst; 1 arm superficial
vein thrombosis; 1 leg cellulitis; and 1 exercise induced
rhabdomyolysis (bilateral). In 11 cases, no clear diagnosis leading
to ACS was found documented in medical or electronic notes, but
all were confirmed as ACS at time of fasciotomy.
The recording of diagnostic signs varied slightly across the
hospitals, with a combined median of 2 out of 3 (AUH 1.5, PRH 2,
RLUH 2 and SRH 1.5).Most relevantly, there was no change since
the introduction of the guidelines (p 0.93), which stipulate all three
are recorded.
There was no significant difference between the 4 centres in
timing from diagnosis to surgery and from fasciotomy to second
visit (p 0.16 and 0.18 respectively). However there was a
difference in timing to definitive wound cover across the centres
(p 0.04). There was no difference between pre and post BOAST10
Table 1
Distribution of patient numbers between units, showing median and mean age and
sex distribution. Abbreviations: Aintree University Hospital (AUH), Royal Preston
Hospital (RPH), Royal Liverpool Hospital (RPL), Salford Royal Hospital (SRH).
Centre Total cases Median age Mean age Male
AUH 20 35 40 14
RPH 21 34 39 14
RLUH 22 40 41 15
SRH 12 38 43 9 3
Combined 75 37 41 52
Please cite this article in press as: D. Bodansky, et al., Acute Compartment Syndrome: Do guidelines for diagnosis and management make a
difference?, Injury (2018), https://doi.org/10.1016/j.injury.2018.04.020
groups in time to fasciotomy (2 h, BOAST standard: 1 h), second
visit (2 days, BOAST standard: 2 days) and definitive closure (p
0.42, 0.72 and 0.28).
There was a positive correlation between the time from
diagnosis to fasciotomy and the number of visits to theatre
(R = 0.73, P 0.0001). However, there was no significant correlation
between the use of split skin grafts and the number of theatre visits
post fasciotomy, (R = 0.21, p 0.95); and time to definitive wound
cover (R = 0.15, p 0.26) as assessed by Spearman Rho coefficient.
We list the recorded complications at a minimum of 1-year post
surgery in Table 4.
Discussion
The wealth of previous data on ACS has been from single
centres, and the aetiology in these studies may be reflective of the
local population. This first multi-centre series of ACS in the United
Kingdom provides a contemporaneous set of demographics and is
widely geographically distributed.
Our data suggests that the mean age of occurrence is about 10
years older than the series reported by McQueen [4], (41 (c/f 32)
and that there is a significant increase in females with ACS (male to
female ratio  5:2 (c/f  10:1)).
Trauma was the major cause in our series, with tibial
fractures being the largest sub-group. However, forearm
fractures dominated that the post-fracture surgery group. None
of the 4 centres used routine pressure monitoring after tibial
fracture treatment, but, given that the 4 hospitals dealt with
major trauma regularly, it is unlikely that an ACS after tibial
nailing would be missed.
We note a significantly higher proportion of non-traumatic
causes of ACS, particularly with anticoagulant use. These are
increasingly significant factors with an ageing population and the
wide introduction of new oral anticoagulants, which are irrevers-
ible [7]. Warfarin was implicated in the single death in our series
and in one of the amputations.
Intravenous drug use was the cause in 4 cases (5.3%). This may
reflect the populations surrounding our four MTCs, based in major
cities [8], a limitation to the generalisability of our study.
Diagnosis was largely clinical, with only 26 patients (34%)
receiving intra-compartmental pressure monitoring. It was not
possible to analyse whether monitoring impacted diagnosis or
management. BOAST recommends undertaking pressure monitor-
ing where clinical signs are not convincing, not as a routine.
The median time to fasciotomy was 2 h after diagnosis, and
the median time for a revisit was 2 days. We acknowledge the
difficulty in establishing the exact time of onset of this evolving
condition. It may be that our retrospective study was under-
powered to measure the data with enough precision (standard 7,
1 h) to demonstrate any effect. The notes are sometimes written
in retrospect and while using admission time and time of onset
of symptoms as a surrogate is possible, the quality of data is
likely to be compromised. Notwithstanding these limitations,
the introduction of the national guidelines emphasising
emergency surgery did not appear to impact the diagnosis or
treatment of ACS.
The time to final closure varied significantly between centres
(6–11 days). This may reflect different surgical practices and/or
theatre list utilisation. Use of split skin grafting as definitive wound
closure also varied, likely due to varying access to plastic surgery
Female assistance. BOAST10 recommends involvement plastic surgeons
6 for tissue coverage without suggesting technique. However it
7 made no difference in the time to definitive wound cover nor the
7 number of surgical visits post fasciotomy.
23
We anticipated that the widely publicised BOAST10 guidelines
would reduce times and improve outcomes. We analysed their
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Table 2
Aetiology of ACS.

Cause Number Site

Traumatic Fracture 21 13 Tibial diaphysis
2 Proximal tibia
2 Femur
1 Radius
1 Foot
1 Ankle
1 Elbow
Post fracture surgery 10 6 Radius (5 ORIF + 1 infected ORIF)
2 Tibial shaft (IM Nail)
1 Femur (IM Nail)
1 Ankle (ORIF)
Crush injury without fracture 9 3 Leg
2 Forearm
2 Thigh
1 Foot
1 Wrist
Haemophiliacs sustaining fall 2 1 Leg
1 Arm
Non-traumatic Post operative 3 1 Leg long neurosurgical operation
1 Forearm FDP hernia repair
1 Forearm proximal row carpectomy
Acquired coagulopathy (Anticoagulation) 5 4 Leg
1 Arm/forearm
(3 Warfarin; 2 high dose LMWH)
Other 14 9 Leg
2 Thigh
1 Arm
1 Forearm
1 hand
Unknown cause 11 7 Leg
1 Forearm
3 Hand

(ORIF = open reduction internal fixation; IM nail = intramedullary nail; FDP = flexor digitorum profundus; LMWH = low molecular weight heparin).

Table 3
It may be that the publication of guidelines does not guarantee
Anatomical site of acute compartment syndrome, listed in order of decreasing their uptake or a change in practice. Mechanisms need to be put in
frequency. place to facilitate their implementation and standardisation.
Locally, this could be through departmental standard operating
Site Frequency (n) Percentage (%)
procedures, audits of performance and nationally, through
Lower leg 44 59
education and analysis of results.
Forearm 15 20
Thigh 7 9 The severity and seriousness of this condition is underscored by
Hand 4 5 the complications found by this dataset. Despite our study showing
Arm 3 4 reasonably early surgical intervention we noted a rate of 34% of
Foot 2 3
serious complications, including 1 death and 4 amputations. There
Total 75 100
was no significant correlation between time from diagnosis to
initial fasciotomy and complication irrespective of complication
severity. We cannot therefore confirm if an earlier fasciotomy, in
impact in the year following their introduction with wide keeping with BOAST guidelines would have reduced the risk of
dissemination, on the grounds that the guidelines would be a complications.
recent, memorable topic. However, we could see no change a year We recognise the limitations of our study. The data collection
after introduction. was retrospective, did not include data from District General

Table 4
Complications post ACS.

Complication Number Notes

Death 1*
Amputation 4* 1 Below Knee (BKA), 2 Above Knee (AKA), 1 Above Elbow (AEA)
Nerve injury Permanent 6*
Temporary 1
Mild 4
Infection Severe 3* Mild: successfully treated with antibiotics alone severe: needed further surgery
Mild 2
Chronic pain 9* 3 diagnosed with CRPS
Other Severe 4* 1 claw toes, 2 renal failure, 1 phantom pain (post AEA) 1 severe scarring, 1 PTSD, 1 limited ROM, 1 delayed union fibula
Moderate 4
TOTAL 38 in 30 patients 27 severe in 22 patients

(* indicates severe complication; CRPS = chronic regional pain syndrome; PTSD = post traumatic stress disorder; ROM = range of movement)

Please cite this article in press as: D. Bodansky, et al., Acute Compartment Syndrome: Do guidelines for diagnosis and management make a
difference?, Injury (2018), https://doi.org/10.1016/j.injury.2018.04.020
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Hospitals, and we accept the possibility of missed cases and
inaccuracies through difficulties in documentation. We only
looked at 3 key aspects of the BOAST10 guidelines that were
readily measurable and therefore cannot comment on the impact it
has had in the other areas.
Conclusion
We believe our large multi-centre series informs of recent
trends in the epidemiology of ACS and provides generalisable
morbidity data. We observed increasingly non-traumatic causes,
often linked to the use of anticoagulants and intravenous drugs.
We believe that a more robust method of data collection, such as a
prospective national audit for all ACS will help refine practice and
promote adherence to national guidelines.
Conflict of interest
None of the authors declare a conflict of interest.
Acknowledgements
The authors would like to recognise the contribution of Mr S
Scott in facilitating this project.
Please cite this article in press as: D. Bodansky, et al., Acute Compartment Syndrome: Do guidelines for diagnosis and management make a
difference?, Injury (2018), https://doi.org/10.1016/j.injury.2018.04.020
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.injury.2018.04.020.
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