Continuous Compartment Pressure Monitoring—Better Than Clinical Assessment?: Commentary on an article by Margaret M. McQueen, MD, FRCSEd(Orth), et al.: “The Estimated Sensitivity and Specificity of Compartment Pressure Monitoring for Acute Compartment Syndrome”
 

Although the pathophysiologic concept of compartment syndrome as progressive myoneural ischemia caused by elevated intracompartment pressure is well accepted, it is not an entity that is easily diagnosed. The difficulty in diagnosing compartment syndrome is problematic because the consequences of missed compartment syndrome can be profound (rhabdomyolysis, muscle fibrosis and contracture, and permanent neurologic deficit), and the only effective prophylactic or therapeutic option of surgical fasciotomy has its own morbidity, expense, and potential complications. Thus, “getting it right” is both extremely important and extremely difficult.

Currently, clinical examination findings and use of intracompartmental pressure monitoring are both most useful in telling us who does not need fasciotomy rather than who does. We can be confident that most patients without concerning physical findings and all patients who have a perfusion pressure (diastolic blood pressure minus intracompartmental pressure) of >30 mm Hg can be safely observed. What we do not know is what we should do with patients who have positive clinical findings or perfusion pressure of <30 mm Hg. Such patients often undergo fasciotomy, but once fasciotomy is done, it is unknown whether compartment syndrome was really present (unless there was necrotic muscle), and therefore whether the fasciotomy was prophylactic, therapeutic, or completely unneeded. This inability to distinguish among traumatized limbs with true ischemic compartment syndrome in its early stages before tissue necrosis has occurred, those with impending compartment syndrome, and those with no compartment syndrome is responsible for our lack of consensus on how to manage at-risk patients.

The senior authors of this article, Dr. McQueen and Dr. Court-Brown, have long been advocates of continuous compartment pressure monitoring, which has been the standard of care at their institution for nearly twenty years. In their two classic articles published in 1996, they showed that a perfusion pressure of >30 mm Hg was safe, that use of this pressure as a threshold for fasciotomy dramatically reduced the rate of unnecessary fasciotomy while not leading to missed compartment syndrome1, and that continuous pressure monitoring led to earlier diagnosis of compartment syndrome with improved outcomes compared with clinical monitoring alone2.

Despite these seemingly clear findings, continuous pressure monitoring continues to be controversial and infrequently used in North America. Other investigators have felt that routine use of continuous pressure monitoring leads to overtreatment with fasciotomy3. Some comparative clinical trials have concluded that there is no benefit to continuous pressure monitoring compared with very strict clinical monitoring alone4.