I read the October ACEP Now article “Spot and Treat Compartment Syndrome” by Dr. Long and Dr. Koyfman with interest. I found the article to have a number of very good points, including the inaccuracy of the history and physical examination. As someone who has been actively involved in this topic for many years, I have several observations.

The article implies that obtaining the intracompartmental pressure is expected when entertaining the diagnosis and that it has a great sensitivity and specificity. The test characteristics of pressure measurement are probably excellent in the hands of someone who uses the technique frequently and acts upon those results. I would propose that person is not an emergency physician.

The problems with the emergency physician measuring the intracompartmental pressure are several.

1. You must measure the pressure in each compartment. There are four compartments in the leg, two in the forearm, and nine (!) in the foot. Being sure that you have measured the pressure in each compartment and using the measurement tool properly are not a given. Then, what would you do with the result? I can’t imagine any surgeon will operate based solely on your measurements or say-so. They will insist on their own evaluation and/or measurements as the authors suggest in the article. Seemingly, this is a redundant and painful procedure for the patient. I have performed pressure measurements several times with an orthopedist, and they are not as straightforward as: Just do it.
2. There will surely be an emergency physician who will avoid (consciously or subconsciously) entertaining the diagnosis if it requires an infrequently used and somewhat cumbersome procedure. Suggesting that intracompartmental pressure is an integral part of the diagnostic workup paints an imprecise and perhaps unnecessarily tortuous path for the emergency physician to make the diagnosis of compartment syndrome.
3. Lastly, fasciotomy is the definitive treatment for compartment syndrome. This is a procedure that no emergency physician should be performing (or has delineated in their staff privileges to perform) regardless of the pressure results (except under the rarest of circumstances). The surgeon will be charged with acting based on their own evaluation that may or may not include pressure measurements.

Emergency physician intracompartmental pressure monitoring has a number of shortcomings. Consequently, let’s not make the process of diagnosing compartment syndrome more onerous than it really is by suggesting that the emergency physician should be performing a procedure that should be more appropriately performed by the person who will be the interventionist. Keep it simple.

So, how should emergency physicians handle cases where they are concerned about compartment syndrome? Call the surgeon and discuss the case.

Jim Webley, MD, FACEP
Pontiac, Michigan