Management of Acute Compartment Syndrome

MANAGEMENT OF ACUTE COMPARTMENT SYNDROME

CLINICAL PRACTICE GUIDELINE

Adopted by the American Academy of Orthopaedic Surgeons Board of Directors 12.07.2018

Endorsed by:

2 Disclaimer

This clinical practice guideline was developed by a physician volunteer clinical practice guideline development group based on a formal systematic review of the available scientific and clinical information and accepted approaches to treatment and/or diagnosis. This clinical practice guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s specific clinical circumstances.

Disclosure Requirement In accordance with AAOS policy, all individuals whose names appear as authors or contributors to this clinical practice guideline filed a disclosure statement as part of the submission process. All panel members provided full disclosure of potential conflicts of interest prior to voting on the recommendations contained within this clinical practice guideline.

Funding Source This clinical practice guideline was funded exclusively through a research grant provided by the United States Department of Defense with no funding from outside commercial sources to support the development of this document.

FDA Clearance Some drugs or medical devices referenced or described in this Clinical practice guideline may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice.

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Published 12/7/18 by the Major Extremity Trauma and Rehabilitation Consortium (METRC) in collaboration with the American Academy of Orthopaedic Surgeons (AAOS) 9400 W Higgins Rosemont, IL First Edition Copyright 2018 by the Major Extremity Trauma and Rehabilitation Consortium (METRC) and the American Academy of Orthopaedic Surgeons (AAOS)

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Table of Contents Summary of recommendations ...... 7 Serum Biomarkers ...... 7 Serum Biomarkers in Late/Missed ACS ...... 7 Pressure Methods ...... 7 Pressure Monitoring in Late/Missed ACS ...... 8 Physical Exam (Awake) ...... 8 Physical Exam (Obtunded) ...... 8 Alternative methods of Diagnosis ...... 9 Fasciotomy Methods ...... 9 Fasciotomy for Late/Missed ACS ...... 9 Associated Fracture ...... 9 Wound Management ...... 10 Pain Management Effects on Diagnosis ...... 10 Development Group Roster ...... 11 Voting Members ...... 11 Non-Voting Oversight Chairs/Staff ...... 11 Introduction ...... 12 Overview/Military Application ...... 12 Goals and Rationale ...... 12 Intended Users ...... 13 Patient Population ...... 14 Burden of Disease ...... 14 Etiology ...... 14 Incidence and Prevalence ...... 14 Risk Factors ...... 15 Emotional and Physical Impact ...... 15 Potential Benefits, Harms, and Contraindications ...... 15 Future Research ...... 15 Methods...... 17 Best Evidence Synthesis ...... 17 Literature Searches ...... 17 Defining the Strength of the Recommendations ...... 17 Voting on the Recommendations ...... 17 Interpreting the Strength of Evidence ...... 18 Peer Review ...... 19 Public Commentary ...... 19 The AAOS Clinical practice guideline Approval Process ...... 19 Revision Plans ...... 19 Clinical practice guideline Dissemination Plans ...... 19 Study Attrition Flowchart ...... 20 Recommendations ...... 21 Serum Biomarkers ...... 21 Serum Biomarkers in Late/Missed ACS ...... 26

5 Pressure Methods ...... 27 Pressure Monitoring in Late/Missed ACS ...... 37 Physical Exam (Awake) ...... 38 Physical Exam (Obtunded) ...... 41 Alternative Methods of Diagnosis ...... 42 Fasciotomy Methods ...... 44 Fasciotomy for Late/Missed ACS ...... 49 Associated Fracture ...... 50 Wound Management ...... 56 Pain Management Effects on Diagnosis ...... 62 Appendices ...... 63 Appendix I – References for Included Literature ...... 64 Appendix II – Excluded Literature ...... 66 Appendix III - Guideline Development Group Disclosures ...... 122 Voting Members’ and Non-Voting Oversight Chairs’ Disclosures ...... 122 Appendix IV – PICO Questions Used to Define Literature Search ...... 124 Appendix V – Study Attrition Flow Chart ...... 125 Appendix VI – Literature Search Strategy ...... 126 INCLUSION CRITERIA ...... 127 Standard Criteria for all CPGs ...... 127 Appendix VII – Participating Peer review Organizations ...... 129 Letters of endorsement from external organizations ...... 130

6 SUMMARY OF RECOMMENDATIONS

SERUM BIOMARKERS

A. Limited evidence supports that myoglobinuria and serum troponin level may assist in diagnosing acute compartment syndrome in patients with traumatic lower extremity injury.

Strength of Recommendation: Limited Description: Evidence from two or more “Low” quality studies with consistent findings or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic test or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention.

B. Moderate evidence supports that, in patients with acute vascular ischemia, femoral vein lactate concentration sampled during surgical embolectomy may assist in the diagnosis of acute compartment syndrome.

Strength of Recommendation: Moderate Description: Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention.

C. Limited evidence supports that myoglobinuria does not assist in diagnosing acute compartment syndrome in patients with electrical injury.

SERUM BIOMARKERS IN LATE/MISSED ACS

In the absence of reliable evidence, it is the opinion of the work group that serum biomarkers do not provide useful information to guide decision making when considering fasciotomy for a presumed late-presentation or missed acute compartment syndrome.

Strength of Recommendation: Consensus Description: There is no supporting evidence. In the absence of reliable evidence, the clinical practice guideline development group is making a recommendation based on their clinical opinion.

PRESSURE METHODS

A. Moderate evidence supports that intracompartmental pressure monitoring assists in diagnosing acute compartment syndrome.

7 B. Moderate evidence supports the use of repeated/continuous intracompartmental pressure monitoring and a threshold of diastolic blood pressure minus intracompartmental pressure >30 mmHg to assist in ruling out acute compartment syndrome.

PRESSURE MONITORING IN LATE/MISSED ACS

In the absence of reliable evidence, it is the opinion of the work group that compartment pressure monitoring does not provide useful information to guide decision making when considering fasciotomy for an adult patient with evidence of irreversible intracompartmental (neuromuscular/vascular) damage.

PHYSICAL EXAM (AWAKE)

Limited evidence supports using serial clinical exam findings to assist in ruling in acute compartment syndrome.

PHYSICAL EXAM (OBTUNDED)

In the absence of reliable evidence, it is the opinion of the work group that without a dependable clinical examination (e.g. in the obtunded patient), repeated or continuous intracompartmental pressure measurements are recommended until acute compartment syndrome is diagnosed or ruled out.

8 ALTERNATIVE METHODS OF DIAGNOSIS

In the absence of reliable evidence, it is the opinion of the work group that there are no reported diagnostic modalities, other than direct pressure monitoring or clinical exam findings, that provide useful information to guide decision making when considering fasciotomy for acute compartment syndrome.

FASCIOTOMY METHODS

In the absence of reliable evidence, it is the opinion of the work group that fasciotomy technique (e.g. one vs two incision, placement of incisions) is less important than achieving complete decompression of the compartments of the affected extremity.

FASCIOTOMY FOR LATE/MISSED ACS

In the absence of reliable evidence, it is the opinion of the work group that performing fasciotomy is not indicated in an adult patient with evidence of irreversible intracompartmental (neuromuscular/vascular) damage. Fracture stabilization, if warranted in these patients, should utilize a technique (external fixation/casting) that does not violate the compartment.

ASSOCIATED FRACTURE

In the absence of reliable evidence, it is the opinion of the work group that operative fixation (external or internal) should be performed for initial stabilization of long bone fractures with concomitant acute compartment syndrome requiring fasciotomy.

9 WOUND MANAGEMENT

Limited evidence supports use of negative pressure wound therapy for management of fasciotomy wounds with regard to reducing time to wound closure and reducing need for skin grafting.

PAIN MANAGEMENT EFFECTS ON DIAGNOSIS

In the absence of reliable evidence, it is the opinion of the work group that neuraxial anesthesia may complicate the clinical diagnosis of acute compartment syndrome. If neuraxial anesthesia is administered, frequent physical examination and/or pressure monitoring should be performed.

10 DEVELOPMENT GROUP ROSTER

VOTING MEMBERS

1. Andrew Schmidt, MD: Co-chair 5. Marcus Philip Coe, MD Orthopaedic Trauma Association American Academy of Orthopaedic Surgeons 2. Colonel Patrick Osborn, MD: Co- chair 6. I. Leah Gitajn, MD Society of Military Orthopaedic Surgeons American Academy of Orthopaedic Surgeons 3. Colonel Anthony Johnson, MD, FAOA 7. Renee Greer, RN, BAN, MSN San Antonio Military Medical Center U.S. Air Force Critical Care Air Transport Team Nurse 4. Luke Balsamo, MD Society of Military Orthopaedic Surgeons

NON-VOTING OVERSIGHT CHAIRS/STAFF

1. David Jevsevar, MD, MBA AAOS 2. Julie B. Samora, MD, PhD, MPH AAOS

AAOS/METRC Staff

1. Ellen J. MacKenzie, PhD, Dean of Bloomberg School of Public Health 2. Jayson Murray, MA, AAOS Director of Clinical Quality and Value 3. Kyle Mullen, MPH, AAOS Manager of Clinical Quality and Value Development 4. Mary DeMars, AAOS Clinical Quality and Value Coordinator 5. Kaitlyn S. Sevarino, MBA, AAOS Manager of Clinical Quality and Value Implementation 6. Peter Shores, MPH, AAOS Biostatistician 7. Anne Woznica, MLIS, AHIP, AAOS Medical Research Librarian

Additional Contributing Members The following MPH graduate student interns participated in the article review and data extraction for this clinical practice guideline: Paul Sliwka and Jennifer Chang

Former AAOS Staff Deborah S. Cummins, PhD, AAOS Director of Research and Scientific Affairs

INTRODUCTION

OVERVIEW/MILITARY APPLICATION This clinical practice guideline is based on a formal systematic review of published studies with regard to the management of acute compartment syndrome of the upper or lower extremity in adults. In addition to providing clinical practice recommendations, this guideline also highlights limitations of the current literature and areas that require future research. This clinical practice guideline addresses ACS in all settings, however, there are many military applications to these recommendations as well.

As we are in the longest period of continuous warfare in US history, topics germane to Tactical Combat Casualty Care remains a primary concern for Military Medicine. The survival rate of extremity injured casualties is associated with 2 Joint Trauma System interventions - educational programs on tourniquet usage and fasciotomy education prior to deployment. As combat trauma is typically composed of the mechanisms of injury associated with acute compartment syndrome (ACS) but in an austere, remote environment, evidence based guidelines for the rapid treatment and comprehensive management of ACS is vital.

In a sample of 17,166 casualties observed in a 10-year period of high casualties (2001-2010), Kragh et al reported 3,313 fasciotomies for an overall fasciotomy rate of 19%. Male combat casualties were 1.7-fold more likely to undergo fasciotomies vs. their female counterparts. As females are not traditionally involved in ground combat, this sex-based dimorphism in fasciotomy may be a result of lower energy injury. In the same cohort, fasciotomy rates increased from 0% in 2001 to 26% in 2010. However, for the same period, survival rates are V- shaped with a nadir occurring in 2005. The observed reversal is temporally associated with implementation of the formal training programs targeting tourniquet use and fasciotomies.

Since the end of active hostilities in Operations Iraqi Freedom and Enduring Freedom, the number of Coalition casualties has decreased from 711 in 2010 to 10 in 2018. Currently, US Service Members are active in the Overseas Contingency Operations (formerly known as the Global War on Terrorism (GWOT)) in over75 countries to include sub-Saharan Africa. This geographical expansion (>4x the land mass of the Continental US) has necessitated the change in the casualty plan from rapid medical evacuation to prolonged field care with an increase in the number of medical personnel deployed at any given time. The low volume of casualties coupled with increased deployment frequency has increased concerns regarding medical skill degradation and loss of lessons learned. Thus, the importance of Evidence Based Clinical Practice Guidelines and Appropriate Use Criteria as a readily available resource to the junior forward deployed medical personnel as well as repository of institutional knowledge. This guideline is intended to be used by all qualified and appropriately trained surgeons, physicians and physician extenders involved in the management of extremity trauma. It is also intended to serve as an information resource for decision-makers and developers of clinical practice guidelines and recommendations.

GOALS AND RATIONALE The purpose of this clinical practice guideline is to guide the clinician’s ability to diagnosis and treat acute compartment syndrome by providing evidence-based recommendations for key

12 decisions that affect the management of patients with extremity trauma. The clinical practice guidelines included in this report are based on the results of a formal systematic review of the available literature regarding acute extremity compartment syndrome that was completed by AAOS staff using a rigorous, standardized process that was conducted between November 2017 and May 2018. A work group consisting of musculoskeletal trauma surgery experts, military surgeons and staff skilled in constructing clinical practice guidelines subsequently agreed upon the following recommendations after determining the diagnostic and therapeutic options informed by good evidence. The work group also reviewed gaps in evidence-based practice and suggested future research directions to improve the management of acute compartment syndrome of the extremities.

Musculoskeletal care is provided in diverse settings by providers of differing backgrounds and experience. This guideline is intended as an educational tool to aid qualified trauma providers’ decision making and improve the quality and efficiency of care. This guideline should not be construed as including all proper methods of care or excluding methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment must be made in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.

A particular challenge in constructing this particular Clinical Practice Guideline is the fact that there are no standard diagnostic criteria for acute compartment syndrome. Clinicians diagnose compartment syndrome using their clinical judgment and/or results of objective measurements (such as compartment pressure), and once the diagnosis is made, emergent fasciotomy is nearly always performed. The lack of a set of clinical standards for the diagnosis of compartment syndrome contributes to wide variation in how compartment syndrome is diagnosed and how often fasciotomy is done [O’Toole 2009]. The therapeutic performance of decompressive fasciotomy is used in many papers as a surrogate for the diagnosis of acute compartment syndrome, despite the fact that they are not the same thing. This is a potential problem when evaluating the literature, since the underlying diagnosis cannot be confirmed in most cases, and there is certainly a bias towards doing fasciotomy in order to avoid medical and medicolegal complications associated with a missed or delayed diagnosis. In this review, we try to be clear about the distinction between fasciotomy (a treatment) and the diagnosis of acute compartment syndrome, which is largely something that cannot be easily controlled for and represents a significant source for bias.

INTENDED USERS This guideline is intended for orthopaedic surgeons and other surgical providers who manage acute compartment syndrome resulting from extremity trauma. While orthopaedic surgeons will have completed medical training, a qualified residency, and potentially sub-specialty training, acute compartment syndrome is not a common occurrence. Outside of established trauma centers, even experienced surgeons may have not been faced with the diagnostic and treatment challenges presented by compartment syndrome. Other surgeons, particularly military surgeons who may be called upon to function outside their normal scope of practice, may have little training in managing compartment syndrome outside of recurrent training courses. Emergency medicine providers, paramedics, physician extenders and other healthcare professionals who may treat injured patients in various practice settings also may benefit from this guideline.

13 The diagnosis and treatment of acute compartment syndrome is based on the assumption that decisions are predicated on the patient and/or the patient’s qualified heath care advocate discussing with the treating provider the available treatments and procedures applicable to the individual patient. Once the patient and or their advocate have been informed of available therapies and have discussed these options with his/her physician, an informed decision can be made. Clinician input based on informed medical knowledge, surgical experience and skill increases the probability of identifying patients with acute compartment syndrome and how to best treat them.

This guideline is not intended for use as a benefits determination document.

PATIENT POPULATION This document addresses the management of acute compartment syndrome of traumatized extremities in adult patients, and the information in this CPG cannot be fully extrapolated to the treatment of children or adolescents. It is not intended to address management of chronic exertional compartment syndrome.

BURDEN OF DISEASE The economic burden of acute compartment syndrome is unknown. Patients with tibia fractures complicated by acute compartment syndrome have a hospital stay that is more than double and charges that are more 2-3 times greater than tibia fractures without compartment syndrome (Schmidt 2011, Crespo 2015). Multiple factors contribute to patient outcomes and treatment costs after trauma; compartment syndrome contributes to worse patient-reported and functional outcomes, including negative effects on quality-of-life that remain more than a year after injury [Giannoudis 2002]. The significant medicolegal aspects surrounding compartment syndrome diagnosis and treatment also contribute to the burden of this condition on patients, providers and the healthcare system [Bhattacharyya, JBJS 2004].

ETIOLOGY Acute compartment syndrome is typically associated with high-energy trauma but can be encountered with low-energy mechanisms of injury, electrocution, vascular injury and following ischemia / reperfusion events, such as after prolonged limb compression in patients with altered mental status (such as a drug overdose or intoxication). Regardless of the etiology, an increase in compartment contents from edema or bleeding raises the intracompartment pressure. If the pathophysiologic process continues and the intramuscular pressure becomes high enough, myoneural capillary blood flow ceases and the compartment contents become ischemic. Depending on the duration of ischemia and the metabolic demands of the affected tissue, permanent tissue injury can occur, which is manifested by ischemic contracture of affected muscles and neural deficits. In some cases, systemic consequences of rhabdomyolysis can occur.

INCIDENCE AND PREVALENCE The incidence of acute compartment syndrome is difficult to ascertain because concrete diagnostic criteria are elusive and most reports use the incidence of fasciotomy as a surrogate for compartment syndrome. Among patients presenting with acute compartment syndrome in one

14 report, the most common diagnoses were tibial diaphyseal fracture (36% of cases), soft tissue injury (23%), distal radius fracture (10%), crush injury and diaphyseal radius / ulna fracture (8% each) (McQueen 2000). For specific injuries, the highest rates seem to be in medial knee fracture-dislocations (53%) and bicondylar tibial plateau fractures (18%) as reported by Stark (2009).

RISK FACTORS Risk factors for acute compartment syndrome of an extremity include fracture (especially of the tibia or forearm), crush injury without fracture, male gender, and age under 35 (McQueen 2000). Bleeding or the use of anticoagulant medications is the cause in 10% of cases of compartment syndrome (McQueen 2000).

EMOTIONAL AND PHYSICAL IMPACT The quality-of-life after lower leg compartment syndrome was studied by Giannoudis et al. (2002). Thirty patients who were a minimum of one-year post-injury completed the EQ-5D (EuroQol) and were compared to age/ sex-matched patients who had sustained closed tibia fracture without compartment syndrome. Patients with a skin-graft reported more pain and discomfort than patients without a skin-graft. Patients whose wounds were closed faster had significantly better self-rated health status than patients in time to wound closure was longer. Finally, the patients reported significantly more problems on the individual dimensions of the EQ-5D than did the control group; however their overall self-rated health was not statistically different (Giannoudis 2002). Other studies have evaluated the long-term results following fasciotomy, demonstrating that the majority of patients experience problems with the leg, most commonly swelling and decreased endurance (van den Brand 2004).

POTENTIAL BENEFITS, HARMS, AND CONTRAINDICATIONS All surgical interventions carry the risk of complication and unforeseen consequences. In the case of ACS, it is possible that failure to perform surgery may lead to far greater disability and morbidity. The accurate diagnosis of ACS is the most confounding aspect in treatment and can be affected by patient factors and the experience of the provider. Failure to diagnose ACS can lead to serious systemic illness, limb loss and significant loss of function. With the resultant high index of suspicion maintained by clinicians in the face of ACS, unnecessary surgery may be performed which may result in prolonged treatment, increased risks of infection and soft tissue damage and resultant disability. Even with an accurate diagnosis, improperly performed fasciotomy increases the risk of increased intracompartmental injury and can complicate the reconstruction of traumatic injuries. Patient factors, including the inciting injury and timing of presentation, always must be considered in the face of clinical signs and symptoms and the clinician’s experience. Synthesis of all available information will facilitate an informed discussion with the patient/surrogate regarding the presence or absence of ACS and the suggested treatment if ACS is suspected or presumed.

FUTURE RESEARCH Consideration for future research is provided for each recommendation within this document. Review of the published literature indicates there is significant controversy regarding the accurate diagnosis of ACS. The dearth of information includes both the definition of ACS and the means to reliably and efficiently obtain objective clinical data. While fasciotomy is widely

15 accepted as the treatment for ACS, it is also commonly done for prophylaxis (in cases of so- called “impending” compartment syndrome), and perhaps even for medicolegal reasons. Since there is no diagnostic standard for ACS, fasciotomy has become a surrogate for the diagnosis of ACS; the substitution of a treatment for a diagnosis represents a significant bias that cannot be easily controlled for in the literature. This is especially true given the strong bias that surgeons have for performing fasciotomy in order to avoid a “missed case”.

Future research should be aimed at defining medical treatments that mitigate the pathophysiologic effects of sustained elevations in compartment pressure so that there are options other than surgical fasciotomy. An important goal would be to develop diagnostic tests that are physiologically-based and provide the clinician with information indicating whether fasciotomy must be done urgently, or whether the patient can be followed with some form of medical management initiated. Finally, methods to tell whether fasciotomy would be beneficial in the late-presenting compartment syndrome would be very significant for the proper management of such patients.

16 METHODS

The methods used to perform this systematic review were employed to minimize bias and enhance transparency in the selection, appraisal, and analysis of the available evidence. These processes are vital to the development of reliable, transparent, and accurate clinical recommendations for management of acute compartment syndrome. To view the full AAOS clinical practice guideline methodology please visit www.aaos.org/cpg.

This clinical practice guideline evaluates the effectiveness of treatments for management of acute compartment syndrome The AAOS approach incorporates practicing physicians (clinical experts) and methodologists who are free of potential conflicts of interest relevant to the topic under study, as 1 recommended by clinical practice guideline development experts.

This clinical practice guideline was prepared by the AAOS Management of Acute Compartment Syndrome Clinical Practice Guideline physician development group (clinical experts) with the assistance of the AAOS Clinical Quality and Value (CQV) Unit in the Department of Research, Quality and Scientific Affairs (methodologists) . To develop this clinical practice guideline , the clinical practice guideline development group held an introductory meeting on November 14, 2017 to establish the scope of the clinical practice guideline. As the physician experts, the clinical practice guideline development group defined the scope of the clinical practice guideline by creating PICO Questions (i.e. population, intervention, comparison, and outcome) that directed the literature search. The AAOS Medical Librarian created and executed the search (see Appendix V for search strategy).

BEST EVIDENCE SYNTHESIS We included only the best available evidence for any given outcome addressing a recommendation. Accordingly, we first included the highest quality evidence for any given outcome if it was available. In the absence of two or more occurrences of an outcome at this quality, we considered outcomes of the next lowest quality until at least two or more occurrences of an outcome had been acquired. For example, if there were two ‘moderate’ quality occurrences of an outcome that addressed a recommendation, we did not include ‘low’ quality occurrences of this outcome. A summary of excluded articles can be viewed in the Appendix II. All of the detailed data for each recommendation can be found in the pages following each recommendation.

LITERATURE SEARCHES The medical librarian conducted a comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials based on key terms and concepts from the clinical practice guideline development group’s PICO questions (Appendix IV). Bibliographies of relevant systematic reviews were hand searched for additional references. All databases were last searched on March 6, 2018 with a limit for English language. The full search strategies are reported in Appendix VI.

DEFINING THE STRENGTH OF THE RECOMMENDATIONS Judging the strength of evidence is only a stepping stone towards arriving at the strength of a clinical practice guideline recommendation. The strength of recommendation (Table 1) also takes into account the quality, quantity, and the trade-off between the benefits and harms of a treatment, the magnitude of a treatment’s effect, and whether there is data on critical outcomes. Table 2 addresses how to interpret the strength of each recommendation.

VOTING ON THE RECOMMENDATIONS The recommendations and their strength were voted on by the guideline development group members during the final meeting. If disagreement between the guideline development group

17 occurred, there was further discussion to see whether the disagreement(s) could be resolved. Recommendations were approved and adopted in instances where a simple majority (60%) of the guideline development group voted to approve; however, the guideline development group had consensus (100% approval) when voting on every recommendation for this guideline.

INTERPRETING THE STRENGTH OF EVIDENCE Table I. Strength of Recommendation Descriptions Overall Strength of Strength Evidence Description of Evidence Quality Strength Visual Evidence from two or more “High” quality studies with Strong Strong consistent findings for recommending for or against the intervention. Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single Moderate Moderate “High” quality study for recommending for or against the intervention. Evidence from two or more “Low” quality studies with consistent findings or evidence from a single Low or “Moderate” quality study recommending for against the Limited Conflicting intervention or diagnostic or the evidence is insufficient Evidence or conflicting and does not allow a recommendation for or against the intervention. There is no supporting evidence. In the absence of reliable evidence, the clinical practice guideline Consensus* No Evidence development group is making a recommendation based on their clinical opinion. Consensus statements are published in a separate, complimentary document.

Table II. Clinical Applicability: Interpreting the Strength of a Recommendation

Patient Strength of Counseling Impact of Future Recommendation (Time) Decision Aids Research Least Important, unless the evidence Strong Least supports no difference between two Not likely to change alternative interventions Moderate Less Less Important Less likely to change Change Limited More Important possible/anticipated Consensus Most Most Important Impact unknown

18 PEER REVIEW Following the final meeting, the clinical practice guideline draft undergoes a two week peer review for additional input from external content experts. Written comments are provided via an electronic structured review form. All peer reviewers are required to disclose their conflicts of interest.

PUBLIC COMMENTARY After modifying the draft in response to peer review, the clinical practice guideline was subjected to a two week period of “Public Commentary.” Commentators consist of members of the Major Extremity Trauma and Rehabilitation Consortium, the AAOS Board of Directors (BOD), members of the Council on Research and Quality (CORQ), members of the Board of Councilors (BOC), and members of the Board of Specialty Societies (BOS). The clinical practice guideline is automatically forwarded to the AAOS BOD and CORQ so that they may review it and provide comment prior to being asked to approve the document. Members of the BOC and BOS are solicited for interest. If they request to see the document, it is forwarded to them for comment. Based on these bodies, over 200 commentators have the opportunity to provide input into this clinical practice guideline. To view comments, visit the ACS CPG Peer Review and Public Comment Report via https://www.aaos.org/tumorinfectionmilitarymedicine/?ssopc=1.

THE AAOS CLINICAL PRACTICE GUIDELINE APPROVAL PROCESS This final clinical practice guideline draft must be approved by the Major Extremity Trauma and Rehabilitation Consortium, and subsequently by the AAOS Committee on Evidence Based Quality and Value Committee, the AAOS Council on Research and Quality, and the AAOS Board of Directors. These decision-making bodies are described in the ACS CPG eAppendix. Their charge is to approve or reject its publication by majority vote.

REVISION PLANS This clinical practice guideline represents a cross-sectional view of current treatment and may become outdated as new evidence becomes available. This clinical practice guideline will be revised in accordance with new evidence, changing practice, rapidly emerging treatment options, and new technology. This clinical practice guideline will be updated or withdrawn in five years in accordance with the standards of the National Guidelines Clearinghouse.

CLINICAL PRACTICE GUIDELINE DISSEMINATION PLANS The primary purpose of the present document is to provide interested readers with full documentation of the best available evidence for various procedures associated with the topic of this review. Publication of most clinical practice guidelines is announced by an Academy press release, articles authored by the clinical practice guideline development group and published in the Journal of the American Academy of Orthopaedic Surgeons, and articles published in AAOS Now. Most clinical practice guidelines are also distributed at the AAOS Annual Meeting in various venues such as on Academy Row and at Committee Scientific Exhibits. The final guideline recommendations and their supporting rationales will be hosted on www.OrthoGuidelines.org.

Selected clinical practice guidelines are disseminated by webinar, an Online Module for the Orthopaedic Knowledge Online website, Radio Media Tours, Media Briefings, and by distributing them at relevant Continuing Medical Education (CME) courses and at the AAOS Resource Center.

19 STUDY ATTRITION FLOWCHART

3607 abstracts reviewed. Search performed on March 6, 2018

3120 articles excluded from title and abstract review

482 articles recalled for full text review

462 articles excluded after full text review for not meeting the a priori inclusion criteria or not best available evidence

20 articles included after full text review and quality analysis

20 RECOMMENDATIONS SERUM BIOMARKERS

A. Limited evidence supports that myoglobinuria and serum troponin level may assist in diagnosing acute compartment syndrome in patients with traumatic lower extremity injury.

RATIONALE (A) One moderate quality study (Alamshah, 2016) showed that myoglobinuria had a moderate/strong relationship to the reference standard of fasciotomy, although surgery was performed based on unspecified pressure measurements and clinical criteria. This study also showed troponin levels to be a strong rule-in test (elevated values were associated with fasciotomy) but a poor rule-out test (normal values were not associated with absence of fasciotomy). This paper included 149 patients, of which 82% had trauma and the others had vascular injury. Patients with crush injury were excluded, which is of interest because this is the classic condition that causes myoglobinuria. Fasciotomy was performed in 14 cases, but the indications for fasciotomy are unclear. This paper does not provide enough data to support any specific role for myoglobinuria as a diagnostic indicator for when acute compartment syndrome is present, but suggests that myoglobinuria is more common in patients with leg trauma (but without crush injury) who undergo fasciotomy.

RATIONALE (B) One high quality study (Mitas, 2014) of patients with acute limb ischemia from femoral artery embolism reported serial lactate measurements taken from the femoral vein just before and at several time points following limb revascularization. The results showed a strong relationship between the difference in blood lactate concentration immediately before and after revascularization and the reference standard of fasciotomy (which was performed based on clinical findings of new sensorimotor deficits and/or intracompartment pressure greater than 30 mmHg). This strong relationship to the reference standard held true at any threshold of blood lactate level between 1 and 3 mmol/L. Although the pressure criterion used could be considered an overly conservative indication for fasciotomy, the findings show that compartment syndrome is more likely when a more profound metabolic disturbance is present. It is important to recognize that this diagnostic approach is only applied ACS occurring in non-trauma patients with acute lower limb ischemia from femoral artery embolism.

21 C. Limited evidence supports that myoglobinuria does not assist in diagnosing acute compartment syndrome in patients with electrical injury.

Strength of Recommendation: Description: Evidence from two or more “Low” quality studies with consistent findings or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic test or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention.

RATIONALE (C) An uncommon cause of extremity compartment syndrome is high-voltage electrical injury, and the diagnosis of ACS in this group is complicated by the associated eschar and the fact that these patients are most-often intubated and cared for in an intensive care unit setting. Biochemical monitoring is therefore of interest in this subset of patients. One moderate quality study (Cancio, 2005) found a weak/poor association between myoglobinuria and the reference standard of fasciotomy (performed based on “clinically evident extremity compartment syndrome or elevated compartment pressures”) for diagnosis of ACS in patients with electrical burn injuries. In relation to this study, neither compartment pressure monitoring nor clinical exam findings have been validated for ACS diagnosis, and treatment standards are biased towards performing fasciotomy/escharotomy. Although there was a weak association between myoglobinuria and performance of fasciotomy in patients with high-voltage electrical injury, the sensitivity and specificity of myoglobinuria are insufficient to recommend it as a diagnostic modality.

FUTURE RESEARCH Future research examining the sensitivity and specificity of biomarkers compared to an appropriate reference standard (e.g. validated and/or comprehensive clinical and pressure diagnosis) in a population of patients suspected of ACS would be invaluable.

22 TABLE 1: QUALITY ASSESSMENT - SERUM BIOMARKER DIAGNOSIS

Representative Clear Selection Detailed Enough to Reference Standard Diagnostic Study Population Criteria Replicate Identifies Target Condition Blinding Other Bias? Inclusion Strength

Alamshah, S. M., Include Moderate 2016 Quality

Cancio, L. C., 2005 Include Moderate Quality

Mitas, P., 2014 Include High Quality

23 TABLE 2: SERUM BIOMARKER DIAGNOSIS

Rule Rule Reference Affected Ref Patient Index In Out Title Quality Limbs Standard Details N Test Sens|Spec LR+|LR- Test Test Alamshah, Moderate Lower limbs Referral to 122 trauma 145 Myoglobinuria 0.93|0.85 6.40|0.08 MODERATE STRONG S. M., Quality fasciotomy or 27 2016 (based on femoral- elevated tibial ICP; no thrombo- clear cut- embolic off) events Alamshah, Moderate Lower limbs Referral to 122 trauma 147 Troponin 0.21|0.98 14.25|0.80 STRONG POOR S. M., Quality fasciotomy or 27 2016 (based on femoral- elevated tibial ICP; no thrombo- clear cut- embolic off) events Mitas, P., High Lower limbs Referral to non-trauma; 55 Blood lactate 1.00|1.00 100.00|0.00 STRONG STRONG 2014 Quality fasciotomy adults with concentration (intrafascial limb [>3mmol/L (Preop pressure >30 ischemia lactate - post and/or new from acute revascularization)] sensorimotor femoral deficit; embolism; 12hrs injury data same at to diagnosis) threshold 1 or 2 mmol/L

24 Rule Rule Reference Affected Ref Patient Index In Out Title Quality Limbs Standard Details N Test Sens|Spec LR+|LR- Test Test Cancio, L. Moderate Upper/Lower Referral to (87% 195 Myoglobinuria 0.59|0.78 2.73|0.52 WEAK POOR C., 2005 Quality limbs fasciotomy >18yrs); (presence of gross (clinical 1000+ volt pigmenturia)(presence and/or electric of gross pigmenturia) elevated injury pts pressure; all (burn done <24hrs location post-injury) unclear)

SERUM BIOMARKERS IN LATE/MISSED ACS

RATIONALE All information available and consideration of the risk of a potentially late fasciotomy should be considered.

POSSIBLE HARMS OF IMPLEMENTATION As noted in this CPG, the diagnosis of ACS at any time point after injury is difficult, uncertain, and potentially controversial, with significant practice variation present. Laboratory value abnormalities alone do not provide sufficient guidance to indicate when fasciotomy is needed. Presuming a missed ACS based on biomarkers may lead to performing fasciotomy on a necrotic compartment with resultant complications. Surgeons should consider irrigation and debridement of an affected limb when faced with evidence of significant infection in an extremity with a presumed missed ACS.

FUTURE RESEARCH While reliable diagnostic criteria for ACS may remain elusive, research should be geared towards determining serum markers that differentiate between reversible ischemia caused by ACS and indicators of neuromuscular necrosis that increases the morbidity of fasciotomy.

PRESSURE METHODS

A. Moderate evidence supports that intracompartmental pressure monitoring assists in diagnosing acute compartment syndrome.

B. Moderate evidence supports the use of repeated/continuous intracompartmental pressure monitoring and a threshold of diastolic blood pressure minus intracompartmental pressure >30 mmHg to assist in ruling out acute compartment syndrome.

RATIONALE There are 2 moderate quality studies (McQueen 2013, Janzing 2001) and 3 low quality studies (Sangwan 2003, Murbarak 1978, Dickson 2003) evaluating the sensitivity and specificity of compartment pressure monitoring for diagnosing ACS. Variability in defining ACS, the type and duration of compartment pressure monitoring (single reading vs. continuous vs. intermittent), and the threshold for fasciotomy complicate interpretation of these studies. However, in all of the studies where a differential pressure of 30 mmHg was used as a cutoff (diastolic blood pressure-ICP or mean arterial pressure- ICP), pressure monitoring showed good sensitivity and/or specificity, indicating that, when combined with clinical symptoms, pressure monitoring can be useful in ruling out compartment syndrome. There was not adequate evidence to support a single absolute pressure cutoff to diagnose ACS.

One moderate strength study (McQueen 2013) examined the sensitivity of continuous compartment pressure monitoring with a threshold for fasciotomy of DBP-ICP <30 for >2 consecutive hours. This study also attempted to quantify false positives and false negatives based on intraoperative findings and clinical sequelae, which lends the study practical strength. While this study found DBP-ICP < 30 to have high sensitivity and specificity, another moderate quality study (Janzing 2001) found this threshold to have poorer specificity, indicating that using DBP-ICP < 30 to diagnose compartment syndrome will result in unnecessary fasciotomies (false positives). The three lower quality studies (Sangwan 2003, Murbarak 1978, Dickson 2003) showed that using DBP-ICP < 30 to diagnose compartment syndrome had good specificity, but were variable in their findings as to the sensitivity of the test.

The findings of another low quality study looking at continuous pressure monitoring vs. no pressure monitoring for tibia fractures (McQueen 1996) supports the fact that few compartment syndromes will be missed using DBP-ICP<30 as a cutoff for diagnosing ACS.

POSSIBLE HARMS OF IMPLEMENTATION Using a threshold of DBP-ICP <30 to diagnose compartment syndrome might lead to overtreatment (fasciotomies for patients without true compartment syndrome). Relying on a single pressure reading as

27 opposed to serial or continuous compartment readings is not a reliable way to diagnose compartment syndrome and may result in missed compartment syndrome. Relying solely on pressure readings should be avoided: clinical suspicion and clinical exam must factor into diagnosis as well.

FUTURE RESEARCH Further studies examining the sensitivity and specificity of pressure measuring methods, techniques and thresholds vs. reference standards that take into account false negatives and false positives would be beneficial.

28 TABLE 3: QUALITY ASSESSMENT - PRESSURE TESTING DIAGNOSIS

Representative Clear Selection Detailed Enough to Reference Standard Other Diagnostic Study Population Criteria Replicate Identifies Target Condition Blinding Bias? Inclusion Strength

Janzing, H. M., 2001 Include Moderate Quality

Dickson, K. F., 2003 Include Low Quality

McQueen, M. M., 2013 Include Low Quality (A)

McQueen, M. M., 2013 Include Moderate (B) Quality

Mubarak, S. J., 1978 Include Low Quality

Sangwan, S. S., 2003 Include Low Quality

Observational Participant Recruitment Allocation Confounding Variables Follow-Up Length Intervention Study Other Bias? Inclusion Strength

McQueen, M. M., 1996 Include Low Quality

Appropriate Prognostic Representative Reason for Follow Up Prognostic Factor Outcome Statistical Study Population Loss Measured Measurement Confounders Analysis Inclusion Strength

Park, S., 2009 Include Low Quality

30 TABLE 4A: PRESSURE TESTING DIAGNOSIS

Reference Rule Rule Title Affected Ref Patient Index Sens|Spec In Out Limbs Quality Standard Details N Test LR+|LR- Test Test Janzing, Moderat Lower leg Fasciotomy or Tibial 97 Repeated 0.83|0.42 1.43|0.40 POOR WEAK H. M., e Quality occurrence of fractures of monitoring 2001 symptoms/functiona 95 children (24hr) ICP l deficiencies after and adults (anterior) 12mo (mostly (>30mmHg) adults) Janzing, Moderate Lower leg Fasciotomy or Tibial 97 Repeated 0.39|0.92 5.12|0.66 MODERATE POOR H. M., Quality occurrence of fractures of monitoring 2001 symptoms/functiona 95 children (24hr) mean l deficiencies after and adults arterial 12mo (mostly pressure - adults) ICP (anterior) (<30mmHg) Janzing, Moderat Lower leg Fasciotomy or Tibial 97 Clinical 0.61|0.97 24.14|0.40 STRONG WEAK H. M., e Quality occurrence of fractures of symptoms 2001 symptoms/functiona 95 children and repeated l deficiencies after and adults monitoring 12mo (mostly (24hr) adults) diastolic BP - ICP (anterior) (<30mmHg)

31 Rule Rule Reference Title Affected Ref Patient Index Sens|Spec In Out Quality Limbs Standard Details N Test LR+|LR- Test Test Janzing, Moderat Lower leg Fasciotomy or Tibial 97 Clinical 0.28|0.99 21.94|0.73 STRONG POOR H. M., e Quality occurrence of fractures of symptoms 2001 symptoms/functiona 95 children and repeated l deficiencies after and adults monitoring 12mo (mostly (24hr) mean adults) arterial pressure - ICP (anterior) (<30mmHg) Janzing, Moderate Lower leg Fasciotomy or Tibial 97 Repeated 0.89|0.65 2.51|0.17 WEAK MODERATE H. M., Quality occurrence of fractures of monitoring 2001 symptoms/functiona 95 children diastolic BP l deficiencies after and adults - ICP 12mo (mostly (anterior adults) 30mmHg) (<30mmHg) Janzing, Moderat Lower leg Fasciotomy or Tibial 97 Repeated 0.33|0.99 26.33|0.68 STRONG POOR H. M., e Quality occurrence of fractures of monitoring 2001 symptoms/functiona 95 children (24hr) mean l deficiencies after and adults arterial 12mo (mostly pressure - adults) ICP (anterior for >1hr) (<30mmHg)

32 Reference Rule Rule Title Affected Ref Patient Index Sens|Spec In Out Quality Limbs Standard Details N Test LR+|LR- Test Test Janzing, Moderat Lower leg Fasciotomy or Tibial 97 Repeated 0.61|0.81 3.22|0.48 WEAK WEAK H. M., e Quality occurrence of fractures of monitoring 2001 symptoms/functiona 95 children (24hr) l deficiencies after and adults diastolic BP 12mo (mostly - ICP adults) (anterior 20mmHg) (<20mmHg) McQueen, Low Lower limbs Fasciotomy intra-op 12-98yrs; 85 Continuous 0.94|0.98 59.82|0.06 STRONG STRONG M. M., Quality assessment or trauma; 0 pressure 2013 (A) clinical follow-up diaphyseal monitoring tibial [differential fractures pressure (DP-ICP) <30 for 2+ hrs] (anterior slit catheter) McQueen, Moderat Lower limbs Referral to 12-98yrs; 85 Continuous 0.97|0.99 96.71|0.03 STRONG STRONG M. M., e Quality fasciotomy (based trauma; 0 pressure 2013 (B) on clinical diaphyseal monitoring assessment) tibial (vs referral) fractures [differential pressure (Diastolic- ICP) <30 for 2+ hrs] (anterior slit catheter)

33 Rule Rule Reference Affected Ref Patient Index In Out Title Sens|Spec Quality Limbs Standard Details N Test LR+|LR- Test Test Dickson, Low Upper/Lowe Clinical diagnosis 5-70yrs; CS . Invasive 0.66|0.96 16.50|0.35 STRONG WEAK K. F., Quality r limbs (significant pain and but no pressure 2003 swelling) mention of measuremen acute t [(DP-ICP) =< 30mm HG] Mubarak, Low Upper/Lowe Continuous pressure 6pts obtunded; 27 Initial ICP 0.64|1.00 63.64|0.36 STRONG WEAK S. J., 1978 Quality r limbs monitoring and/or includes by wick referral to tensor/buttock catheter (>= pts fasciotomy 30 mm Hg)

Mubarak, Low Upper/Lowe Continuous pressure 6pts 27 Initial ICP 1.00|1.00 100.00|0.0 STRONG STRONG S. J., 1978 Quality r limbs monitoring and/or obtunded; by wick 0 referral to includes catheter fasciotomy tensor/buttoc (>=20 mm k pts Hg) Sangwan, Low Upper/Lower Continuous pressure Suspected CS 10 Initial ICP 1.00|0.43 1.75|0.00 POOR STRONG S. S., Quality limbs monitoring and/or of either limb 0 (saline 2003 referral to apparatus fasciotomy (2-90hr 30cm saline) injury to admission [>=30cm range) saline (approx 22mmHg)]

34 Reference Rule Rule Title Affected Ref Patient Index Sens|Spec In Out Quality Limbs Standard Details N Test LR+|LR- Test Test Sangwan, Low Upper/Lower Continuous pressure Suspected CS 10 Initial ICP 0.83|1.00 82.76|0.17 STRONG MODERATE S. S., Quality limbs monitoring and/or of either limb 0 (saline 2003 referral to apparatus fasciotomy (2-90hr 40cm saline) injury to admission [>=40cm range) saline (approx 30mmHg)]

TABLE 4B: PRESSURE MONITORING INTERVENTION

Outcome Affecte d Patient Treatme nt Mean1/P 1 Treatment Mean2/P 2 Effect Resul t Favored Referen ce Qualit y Methods Details Limbs Details 1 N (SD1) 2 N (SD2) Measure (95% Treatment Title (Details) 1 (Details) 2 CI) McQueen, Low Complications Lower Avg 28yrs Sigmore early Pre-op 12 0.00% Pre-op 11 90.91% RD - 0.91(- Treatment M. M., 1996 Quality (Muscle (all >14); fasciotomy in pressure single/no n- 1.08,- 1 weakness, trauma; tibial Tx1; monitoring monitored 0.74) Significant contracture, diaphyseal diagnosed by and double pressure test (P- value<.0 infection) fractures (23 clinical or both incision and double 5) closed, 2 clinical/pressure fasciotomy incision open) (anterior slit fasciotomy catheter)

35 TABLE 4C: PRESSURE MONITORING INTERVENTION

Model Reference Outcome Affected Patient Prognostic (confounding Result Title Quality Details Limbs Details Methods Factor N Statistic adjustment) (p-value) Significance Park, S., Low ACS Lower Acute Diaphyseal, Mean 414 Beta Multivariate 0.0246 MAP is not 2009 Quality diagnosis tibial proximal, or arterial coefficient logistic regression (0.108) significantly fracture pts distal pressure (pvalue) (age, mean arterial associated (adults and (on pressure, and with children admission) concomitant injury) diagnosis of with closed ACS growth plates)

PRESSURE MONITORING IN LATE/MISSED ACS

RATIONALE Determining when ACS has caused irreversible damage to the nerves, vessels and/or muscle in a given compartment is difficult in the absence of a reliable clinical history. There is no convincing clinical data to indicate that multiple compartment pressure checks can help determine when irreversible damage has occurred. There is also no conclusive clinical data to suggest that elevated compartment pressures in a patient with known irreversible intracompartmental damage are an indication for fasciotomy. Fasciotomy performed on a limb with irreversible intracompartmental damage carries significant morbidity.

POSSIBLE HARMS OF IMPLEMENTATION The indication for fasciotomy should be based on a reliable clinical history and exam. Assuming the viability of the compartment necrosis can lead to a missed diagnosis while performing fasciotomy on a necrotic compartment may lead to significant morbidity.

FUTURE RESEARCH Determining reliable compartment pressure measurements that indicate the progression to irreversible ischemia would significantly aid the clinician seeking to avoid the morbidity of fasciotomy in this population.

PHYSICAL EXAM (AWAKE)

Limited evidence supports using serial clinical exam findings to assist in ruling in acute compartment syndrome.

RATIONALE One moderate quality study (Janzing, 2001) showed serial clinical testing (e.g. pain, pallor, pulse, swelling, etc.) to have a moderate association with the performance of fasciotomy for presumed ACS in patients with tibia fractures. Patients were examined and compartment pressures checked hourly for 6 hours then every 3 hours for at least 24 hours. ACS was defined as a patient indicated for fasciotomy or those who suffered a sequelae attributed to ACS, not a specific intracompartmental pressure or operative findings. This study also compared different thresholds for indicating patients for fasciotomy with clinical examination being specific (0.87) for surgery but less sensitive (0.67) than intracompartmental pressure monitoring. Pressure monitoring in symptomatic patients did obviate the need for fasciotomy in some cases, however the authors acknowledge the inability to truly diagnose ACS, using indicated fasciotomy as a surrogate for the diagnosis.

Two other low quality studies (Dickson, 2003; Mubarak, 1978) assessed clinical symptoms for the diagnosis of ACS, but they were deemed relevant only to the pressure testing recommendations (2a and 2b). Mubarak, et al utilized compartment pressure monitoring in patients who presented with clinical symptoms/signs of ACS. These clinical findings were used as the threshold to perform further intracompartmental testing instead of being compared to pressure values. Similarly, Dickson et al identified patients with pain and swelling for inclusion in studying a new device comparing limb hardness to intracompartmental pressure values.

The four included studies included patients without acute trauma and varying definitions for ACS, with dissimilar roles of clinical diagnosis for diagnosing ACS, thus the findings should be interpreted with caution.

POSSIBLE HARMS OF IMPLEMENTATION Due to the difficulty in accurately diagnosing true compartment syndrome, reliance on clinical examination may lead to both missed diagnosis and, conversely, overtreatment with “unnecessary” fasciotomy. Many clinicians rely on exam findings and the suspicion of ACS should prompt further investigation with serial exams or pressure measurement. Reliance on a single negative exam may result in a missed diagnosis and dependence solely on classic symptoms may lead to overdiagnosis.

FUTURE RESEARCH The unreliability of clinical examination further supports the need for research into noninvasive compartment pressure/perfusion techniques as well as delineation of clear pressure values that indicate the presence of ACS.

TABLE 5: QUALITY ASSESSMENT - PHYSICAL/CLINICAL DIAGNOSIS

Representative Clear Selection Detailed Enough to Reference Standard Identifies Other Diagnostic Study Population Criteria Replicate Target Condition Blinding Bias? Inclusion Strength

Janzing, H. M., Include Moderate 2001 Quality

Thakur, N. A., Include Low Quality 2012

39 TABLE 6: PHYSICAL/CLINICAL DIAGNOSIS

Rule Rule Reference Affected Ref Patient Index In Out Title Quality Limbs Standard Details N Test Sens|Spec LR+|LR- Test Test Thakur, N. Low Foot Referral to Trauma pts; 18491 Injury severity 0.16|0.78 0.74|1.07 POOR POOR A., 2012 Quality fasciotomy adults and score (ISS) children (severe/very severe 16-75) Janzing, H. Moderate Lower Fasciotomy or Tibial 97 Serial clinical 0.67|0.89 5.85|0.38 MODERATE WEAK M., 2001 Quality leg occurrence of fractures of symptom symptoms/functional 95 children monitoring deficiencies after and adults (Presence of 12mo (mostly pain, swelling, adults) pallor, sensibility, movement, pulse, stretch pain)

PHYSICAL EXAM (OBTUNDED)

RATIONALE A high suspicion for compartment syndrome should always be maintained in the obtunded patient. In contradistinction to the patient with an unknown clinical timeline leading to compartment syndrome, the timeline of the obtunded patient’s clinical course might be more obvious. Mechanism and/or previous surgical interventions (i.e. vascular repair, ORIF) should alert surgeons to the potential for ACS, and we recommend that surgeons closely monitor these patients and ensure that appropriate perfusion is maintained and hypotension avoided. With at-risk patients and equivocal findings of acute compartment syndrome, fasciotomy is less morbid than the consequences of a missed acute compartment syndrome.

POSSIBLE HARMS OF IMPLEMENTATION In this patient population, there is limited risk in performing serial examination of the affected extremity. Increased risk may be introduced if an inappropriate threshold is used to diagnosis acute compartment syndrome in these patients allowing acute compartment syndrome to evolve into irreversible intracompartmental damage.

ALTERNATIVE METHODS OF DIAGNOSIS

RATIONALE Only one low quality study (Dickson, 2003) meeting the inclusion criteria for this CPG was found that addressed any diagnostic modalities other than clinical or pressure testing. This study showed that in patients with a clinical diagnosis suggesting or confirming compartment syndrome, a “hardness ratio” of 2 or more had a weak association to the reference standard of a clinical diagnosis of ACS (as determined by the attending physician’s clinical assessment). Hardness measurements were made using an investigational device consisting of a force plate that was applied to the skin. The hardness of the compartment with the highest compartment pressure was comparted to the final clinical assessment, and diagnostic parameters calculated. In particular, this diagnostic method had low specificity, resulting in a significant number of false positive diagnoses, leading the authors not to recommend this as a useful diagnostic modality.

Many other examples of alternative diagnostic modalities have been considered to be of potential value for the diagnosis of ACS, including near-infrared spectroscopy (NIRS), electromyography (EMG), and pH testing. However, at the time of publication of this CPG, these modalities were not supported by any published literature meeting the inclusion criteria for this review. It is the opinion of the panel that this is an area of significant research with potential clinical impact, and readers should continue to review the published literature as new data regarding new diagnostic modalities for ACS become available.

POSSIBLE HARMS OF IMPLEMENTATION Misdiagnosis could lead irreversible intracompartmental damage.

FUTURE RESEARCH Studies examining the sensitivity and specificity of various diagnostic modalities (e.g. NIRS, Imaging, NCS, etc.) as compared to an appropriate reference standard (e.g. validated and/or comprehensive clinical and pressure diagnosis) in a population of patients suspected of ACS may have significant impact on clinicians’ ability to accurately diagnose acute compartment syndrome in a timely fashion.

42 TABLE 7: QUALITY ASSESSMENT – ALTERNATIVE METHODS OF DIAGNOSIS

Reference Standard Representative Clear Selection Detailed Enough to Identifies Target Diagnostic Study Population Criteria Replicate Condition Blinding Other Bias? Inclusion Strength

Dickson, K. F., Include Low 2003 Quality

TABLE 8: ALTERNATIVE METHODS OF DIAGNOSIS

Rule Rule Reference Affected Ref Patient Index In Out Title Quality Limbs Standard Details N Test Sens|Spec LR+|LR- Test Test Dickson, K. Low Quality Upper/Lower Clinical 5-70yrs; CS 75 Hardness 0.68|0.82 3.78|0.39 WEAK WEAK F., 2003 limbs diagnosis but no measurements (significant mention of (highest) pain and acute (hardness ratio swelling) => 2)

FASCIOTOMY METHODS

RATIONALE Four low quality studies (Bible, 2013; Jang, 2017; Kanj, 2013; Heemskerk, 2003) examined various fasciotomy techniques displaying varying results and inconsistent outcomes, which led to the lack of an evidence-based recommendation for this topic.

Clinicians should consider the soft tissue envelope when determining incision placement as the literature does not clearly suggest an advantage or disadvantage for choosing different techniques. Surgeons should choose the fasciotomy technique deemed best to allow for full decompression of the involved compartments and may be tailored to other considerations such as plans for staged fixation. For the inexperienced clinician, it is recommended that the 2-incision method be used.

POSSIBLE HARMS OF IMPLEMENTATION Incomplete fasciotomy can have severe consequences. In the war wounded, the need for fasciotomy revision is associated with a 4-fold increase in mortality.

FUTURE RESEARCH While fasciotomy is not technically challenging, research into the most effective educational tools to improve fasciotomy techniques may be of benefit. A fasciotomy education program, as conducted in the U.S. military, improved survival rates however, the rates of delayed fasciotomy did not change.

44 TABLE 9: QUALITY ASSESSMENT – FASCIOTOMY METHODS

Observational Other Bias? (If Intervention Participant Confounding Follow-Up retrospective Study Recruitment Allocation Variables Length comparative, mark Yes) Inclusion Strength

Bible, J. E., Include Low Quality 2013

Jang, Y. S., Include Low Quality 2017

Kanj, W. W., Include Low Quality 2013

Representative Reason for Follow Prognostic Factor Outcome Appropriate Prognostic Study Population Up Loss Measured Measurement Confounders Statistical Analysis Inclusion Strength

Heemskerk, J., Include Low Quality 2003

45 TABLE 10A: FASCIOTOMY METHODS

Reference Outcome Treatment 1 Mean1/P 1 Treatment 2 Mean2/P 2 Effect Result Favored Title Details Affected Patient (Details) (SD1) (Details) (SD2) Measure (95% Treatmen Quality Limbs Details Methods N1 N2 CI) t Bible, J. Low Non- Lower >= 18yrs; Tibial Double incision 22 18.18% Single incision 59 11.86% RR 1.53(0.50,4.73) Not E., 2013 Quality union leg tibial plateau fasciotomy; plate fasciotomy; Significant (tibial plateau fixation plate fixation (P- plateau) fracture value>.05 (22 open, ) 38 closed) Bible, J. Low Deep Lower >= 18yrs; Tibial Double incision 22 22.73% Single incision 59 25.42% RR 0.89(0.37,2.17) Not E., 2013 Quality infection leg tibial plateau fasciotomy; plate fasciotomy; Significan (tibial plateau fixation plate fixation t (P- plateau) fracture value>.05 (22 open, ) 38 closed) Bible, J. Low Non- Lower >= 18yrs; Tibial Dual incision 24 12.50% Single incision 36 19.44% RR 0.64(0.18,2.24) Not E., 2013 Quality union leg tibial shaft shaft fasciotomy; fasciotomy; Significant (tibial fracture intramedullary nail intramedullary (P- shaft) (22 open, nail value>.05 38 closed) ) Bible, Low Deep Lowe >= 18yrs; tibial Tibial shaft Dual incision 24 8.33% Single 36 2.78% RR 3.00(0.29,31.2 Not J. E., Quality infection r leg shaft fracture (22 fasciotomy; incision 8) Significant 2013 (tibial shaft) open, 38 closed) intramedullary fasciotomy; (P-value>.05) nail intramedullary nail Jang, Low Amputation Upper 270 total limbs of Diagnosed Early (<8hr 154 51.30% Late (>8hr 114 63.16% RR 0.81(0.66,1.00 Not Y. S., Quality (early vs arm adults; high- by clinical from injury) from injury) ) Significant 2017 late) voltage injury; and US straight straight (P-value>.05) con done 1996- testing midline midline 2002 and mid curved curved done 2003-2007 incision or incision or conventional conventional fasciotomy fasciotomy (Green's (Green's volar-ulnar volar-ulnar incision) incision)

46 Reference Outcome Treatment Mean1/P Treatment Mean2/P Effect Result Favored Title Details Affected Patient 1 1 2 2 Measure (95% Treatment Quality Limbs Details Methods (Details) N1 (SD1) (Details) N2 (SD2) CI) Jang, Low Amputation Upper 184 total limbs of Diagnosed Early 100 60.00% Late 84 69.05% RR 0.87(0.70,1.08 Not Y. S., Quality (early con vs arm adults; high- by clinical conventional conventional ) Significant 2017 late con) voltage injury; and US fasciotomy fasciotomy (P-value>.05) con done 1996- testing (<8h after (>8h after 2002 and mid injury; injury; done 2003-2007 Green's Green's volar-ulnar volar-ulnar incision) incision) Jang, Low Amputation Upper 154 total limbs of Diagnosed Early 100 60.00% Early straight 54 35.19% RR 1.71(1.15,2.53 Treatment 2 Y. S., Quality (early con vs arm adults; high- by clinical conventional midline ) Significant 2017 early mid) voltage injury; and US fasciotomy curved (P-value<.05) con done 1996- testing (<8h after incision 2002 and mid injury; fasciotomy done 2003-2007 Green's (<8h after volar-ulnar injury) incision) Jang, Low Amputation Upper 86 total limbs of Diagnosed Early straight 54 35.19% Late straight 30 46.67% RR 0.75(0.45,1.28 Not Y. S., Quality (early mid vs arm adults; high- by clinical midline midline ) Significant 2017 late mid) voltage injury; and US curved curved (P-value>.05) con done 1996- testing incision (<8h incision (>8h 2002 and mid after injury) after injury) done 2003-2007 Jang, Low Amputation Uppe 114 total limbs of Diagnosed Late 84 69.05% Late straight 30 46.67% RR 1.48(0.98,2.23 Not Y. S., Qualit (late con vs r arm adults; high- by clinical conventional midline ) Significant 2017 y late mid) voltage injury; and US fasciotomy curved (P-value>.05) con done 1996- testing (>8h after incision 2002 and mid injury; fasciotomy done 2003-2007 Green's (>8h after volar-ulnar injury) incision)

47 Treatment Mean1/P Treatment Mean2/P Result Reference Outcome Affected Patient Effect Favored Quality Methods 1 N1 1 2 N2 2 (95% Title Details Limbs Details Measure Treatment (Details) (SD1) (Details) (SD2) CI) Kanj, Low Minor Upper Children; Diagnosed Early; =< 12 25.00% Late; > 24h 10 20.00% RR 1.25(0.26,6.07 Not W. W., Quality permanent limbs trauma/IV by clinical 24h from from injury; ) Significant 2013 change infiltration/ and/or injury; single single or (P-value>.05) infection cause pressure or double double tests fasciotomy fasciotomy (>=30mmH g or DP- ICP <30)

TABLE 10B: FASCIOTOMY METHODS

Reference Quality Outcome Affected Patient Methods Prognostic N Model (confounding Result Significance Title Details Limbs Details Factor adjustment) Heemskerk, Low Dysfunction, Lower Avg age 52 40 Age <50 36 Multivariate logistic Author Age <50 is J., 2003 Quality amputation, (range 19- fasciotomies regression (age, Reported significantly or death 91); trauma in limbs total creatinine, acute associated and non- arterial obstruction, with better trauma; all and fracture) outcomes of lower leg fasciotomy fasciotomies

FASCIOTOMY FOR LATE/MISSED ACS

RATIONALE Patients may present with evidence of advanced compartment syndrome of uncertain but likely prolonged duration, as in the case of a patient found obtunded or incapacitated. When evidence of irreversible muscle ischemia and necrosis (rhabdomyolysis) is observed, as indicated by the presence of myoglobinuria, renal failure, and dramatic elevations in creatine phosphokines (CPK), fasciotomy may increase the potential for further reperfusion injury. In addition, exposure of necrotic muscle by performing fasciotomy may necessitate extensive debridement and create large wounds with the potential for soft tissue infection. For these reasons, the panel recommends that fasciotomy not be performed in such circumstances. In such cases where there is an associated fracture, operative fracture care should be approached with caution and fixation methods that do not violate the compartment (external fixation, casting) should be considered.

POSSIBLE HARMS OF IMPLEMENTATION When presented with the possibility of late ACS, clinicians should be wary of erroneously assuming the patient has an irreversible injury. In the absence of any reliable techniques to accurately determine the timing of the compartment syndrome, the clinician is left with few options. Fasciotomies in an extremity with irreversible compartment syndrome can lead to systemic reperfusion injuries and exposes devitalized muscle potentially increasing the risk of infection. A small incision to determine the presence or absence of devitalized muscle in the compartment may be a reasonable option. If necrotic muscle is found, extension of the incision is not advised. Fracture stabilization is warranted in these extremities in certain situations. In the short term, temporizing stabilization with external fixation or casting is preferred.

FUTURE RESEARCH Future research to define serum biomarkers or determine imaging modalities that reliably establish the extent of muscle necrosis would be beneficial.

ASSOCIATED FRACTURE

RATIONALE One low quality study (Kim, 2017) supports the use of either immediate intramedullary nailing or internal fixation in tibial fractures requiring fasciotomy. This study retrospectively reviewed a small cohort of patients who underwent fasciotomy with concomitant intramedullary nailing, internal plate fixation, or external fixation. Patients later underwent delayed fasciotomy closure or skin grafting. The investigators found no difference in functional outcomes or complications.

POSSIBLE HARMS OF IMPLEMENTATION Early internal fixation with open fasciotomy wounds may lead to contamination of hardware and deep infection. The above study must be interpreted with caution.

FUTURE RESEARCH In the absence of studies randomizing patients requiring fasciotomy for ACS to either internal or external fixation, analysis of complications and patient outcomes in large, matched, stratified, controlled treatment groups at equal follow up times would be beneficial.

50 TABLE 11: QUALITY ASSESSMENT - MANAGEMENT OF ASSOCIATED FRACTURES

Observational Other Bias? (If Intervention Participant Confounding retrospective comparative, Study Recruitment Allocation Variables Follow-Up Length mark Yes) Inclusion Strength

Kim, T. H., Include Low Quality 2017

TABLE 12: MANAGEMENT OF ASSOCIATED FRACTURES

Treatment Treatment Result Reference Outcome Affected Patient Mean1/ Mean2/ Effect Favored Quality Methods 1 N 2 N (95% Title Details Limbs Details P1 (SD1) P2 (SD2) Measure Treatment (Details) 1 (Details) 2 CI)

Kim, T. Low Complications Lower >18yrs Diagnosed Initial 20 10.00% Initial 15 13.33% RR 0.75(0.12,4.7 Not H., 2017 Quality (Infection, leg ; acute by clinical internal/ external 3) Significant delayed tibial judgement definitive fixation (P- union, fractur of fixation (switched value>.0 nonunion, e; ACS attending to 5) nerve orthopaedic internal damage, surgeon; after poor done average prognosis) immediately of 9.3 after days) fasciotomy ; single/ double 4 compartment fasciotomy with NPWT

Treatment Mean1/ Treatment Mean2/ Result Reference Outcome Affected Patient N Effect Favored Quality Methods 1 P1 2 P2 (95% Title Details Limbs Details 1 N Measure Treatment (Details) (SD1) (Details) (SD2) CI) 2 Kim, T. Low LEFS; Lower >18yrs Diagnosed Initial 20 74.3(7.4 Initial 15 74(8.40) MeanD 0.3(- Not H., 2017 Quality lower leg ; acute by clinical internal/ 0) external if 5.05,5.65) Significant extremity tibial judgement definitive fixation (P- functional fractur of fixation (switched value>.0 scale e; ACS attending to 5) orthopaedic internal surgeon; after done average immediately of 9.3 after days) fasciotomy ; single/ double 4 compartment fasciotomy with NPWT

52 Treatment Treatment Result Reference Outcome Affected Patient N Mean1/ N Mean2/ Effect Favored Quality Methods 1 2 (95% Title Details Limbs Detail s 1 P1 (SD1) 2 P2 (SD2) Measure Treatment (Details) (Details) CI)

Kim, T. Low Time to Lower >18yrs Diagnosed Initial 20 5.6(2.10) Initial 15 6.3(2.70) MeanD -0.7(- Not H., 2017 Quality union leg ; acute by clinical internal/ external if 2.35,0.95) Significant (months) tibial judgement definitive fixation (P- fractur of fixation (switched value>.0 e; ACS attending to 5) orthopaedic internal surgeon; after done average immediately of 9.3 after days) fasciotomy ; single/ double 4 compartment fasciotomy with NPWT

53 Patient Treatment Treatment Reference Affected Detail 1 Mean1/ 2 Mean2/ Effect Result Favored Title Quality Outcome Limbs s (Details) N P1 (Details) N P2 Measure (95% Treatment Details Methods 1 (SD1) 2 (SD2) CI) Kim, T. Low Time to Lower >18yrs Diagnosed Initial 20 10.9(3.6 Initial 15 10.4(2.4 MeanD 0.5(- Not H., 2017 Quality wound leg ; acute by clinical internal/ 0) external 0) if 1.49,2.49) Significa nt closure tibial judgement definitive fixation (P- (days) fractur of fixation (switched value>.0 e; ACS attending to 5) orthopaedic internal surgeon; after done average immediately of 9.3 after days) fasciotomy ; single/ double 4 compartment fasciotomy with NPWT

54 Treatment Treatment Result Reference Outcome Affected Patient N Mean1/ Mean2/ Effect Favored Quality Methods 1 2 N (95% Title Details Limbs Details 1 P1 (SD1) P2 (SD2) Measure Treatment (Details) (Details) 2 CI)

Kim, T. Low Additional Lower >18yrs Diagnosed Initial 20 10.00% Initial 15 20.00% RR 0.50(0.10,2.6 Not H., 2017 Quality surgery leg ; acute by clinical internal/ external 3) Significant needed tibial judgement definitive fixation (P- fractur of fixation (switched value>.0 e; ACS attending to 5) orthopaedic internal surgeon; after done average immediately of 9.3 after days) fasciotomy ; single/ double 4 compartment fasciotomy with NPWT

WOUND MANAGEMENT

Limited evidence supports use of negative pressure wound therapy for management of fasciotomy wounds with regard to reducing time to wound closure and reducing need for skin grafting.

RATIONALE There was one moderate strength (Li, 2015) and three low strength (Zannis, 2009; Mittal, 2017; Krticka, 2016) studies evaluating wound management after fasciotomy. Li et al. found that use of negative pressure wound therapy resulted in a decrease in days to wound closure/coverage (9 days versus 14 days). Zannis et al. found that negative pressure wound therapy resulted in decreased need for split thickness skin graft in both the lower limb (17% versus 44%, RR 0.39) and upper limb (43% versus 66%, RR 0.67).

Of the three studies that reported important but rare outcomes including infection and/or other complications, all were underpowered to adequately assess these rare outcomes (subject sizes: 52 patients in Li et al., 63 patients in Krticka et al. and 50 patients in Mittal et al.). Krticka 2016 compared vacuum- assisted closure with dermatotaxis technique versus dressing fabrics and reported that dressing fabrics resulted in a higher rate of infection that was not statistically significant (9.5% versus 14.3%). For context, based on this rate of infection a study would require 1,478 patients (739 per group) to be adequately powered to detect a statistically significant difference with 80% power, assuming an alpha of 5%.

Mittal et al. compared two specific dermatotaxis techniques to aid wound closure without use of negative pressure wound therapy and found that use of tensioned wires (as opposed to sutures) resulted in higher risk of infection (12% versus 4%, RR 3).

POSSIBLE HARMS OF IMPLEMENTATION We believe that there is no harm associated with use of negative pressure wound therapy to assist wound management/wound closure of fasciotomy wounds, particularly if used in the short term. However, there may be a relationship between time to wound closure/coverage and risk of infection, particularly in the setting of metallic implants. However, this is not been examined in the literature in this patient population. Furthermore, the risk benefit ratio of dermatotaxis techniques are not yet clear.

FUTURE RESEARCH Future research is needed to further clarify the relative benefits associated with use of negative pressure wound therapy, with particular consideration for austere environments. This work has important implications for forward surgical teams utilized by the military. However, there may be barriers to performing this work in civilian settings due to the substantial benefits of negative pressure wound therapy in terms of patient care (fewer dressing changes, easier nursing care) as well as theoretical benefits (including reduction in nosocomial contamination due to sterile placement in the operating room, improved granulation tissue formation to improve skin graft bed). Adequately powered high quality

56 studies are needed to explore the relationship between management of fasciotomy wounds and complication such as infection as well as rate of and time to delayed wound closure and/or skin graft. Independent variables important to study include type of wound care method (ie negative pressure wound therapy versus wet to dry guaze), use of dermatotaxis techniques (ie “Jacob’s ladder” or “shoestring” technique versus traditional), time to closure or skin graft, timing for definative fixation/definative hardware. Both hard outcomes as well as functional outcomes and health-related quality of life outcomes are needed to adequately guide decision-making.

57 TABLE 13: QUALITY ASSESSMENT - FASCIOTOMY WOUND MANAGEMENT

Randomized Intervention Random Sequence Allocation Incomplete Outcome Selective Other Study Generation Concealment Blinding Data Reporting Bias Inclusion Strength

Li, W., 2015 Include Moderate Quality

Other Bias? (If Observational Participant Confounding retrospective comparative, Intervention Study Recruitment Allocation Variables Follow-Up Length mark Yes) Inclusion Strength

Krticka, M., 2016 Include Low Quality

Mittal, N., 2017 Include Low Quality

Zannis, J., 2009 Include Low Quality

58 TABLE 14: FASCIOTOMY WOUND MANAGEMENT

Treatment Treatment Result Reference Outcome Affected Patient 1 Mean1/P1 2 Mean2/P2 Effect (95% Favored Title Quality Details Limbs Details Methods (Details) N1 (SD1) (Details) N2 (SD2) Measure CI) Treatment Krticka, Low Osteomyelitis Lower Adults; Diagnosed by NPWT and 42 4.76% Combined 21 4.76% RR 1.00(0.10,10.41) Not M., 2016 Quality events leg trauma clinical EDL (day 2); dressing Significant symptoms; single-incision fabrics (P- Sig more fasciotomy (COM); value>.05) suturing in single-incision Tx1; Sig less fasciotomy DE grafting in Tx1; op max 2hrs post diagnosis Krticka, Low Necrotic events Lower Adults; Diagnosed by NPWT and 42 7.14% Combined 21 28.57% RR 0.25(0.07,0.90) Treatment M., 2016 Quality leg trauma clinical EDL (day 2); dressing 1 symptoms; single-incision fabrics Significant Sig more fasciotomy (COM); (P- suturing in single-incision value<.05) Tx1; Sig less fasciotomy DE grafting in Tx1; op max 2hrs post diagnosis Krticka, Low Infection events Lower Adults; Diagnosed by NPWT and 42 9.52% Combined 21 14.29% RR 0.67(0.16,2.71) Not M., 2016 Quality leg trauma clinical EDL (day 2); dressing Significant symptoms; single-incision fabrics(COM); (P- Sig more fasciotomy single-incision value>.05) suturing in fasciotomy Tx1; Sig less DE grafting in Tx1; op max 2hrs post diagnosis Mittal, N., Low Infection events Lower 21 to 60 Diagnosed by Dermotaxis 25 12.00% Loop suture 25 4.00% RR 3.00(0.33,26.92) Not 2017 Quality limbs years old; clinical (two parallel (involves Significant closed examination wires passed using (P- fracture; through dermis corrugated value>.05) trauma; lower and drains and extremity interconnected Ethilon (no. 1) by compression suture) device)

59 Treatment Treatment Result Reference Outcome Affected Patient 1 Mean1/P1 2 Mean2/P2 Effect (95% Favored Title Quality Details Limbs Details Methods (Details) N1 (SD1) (Details) N2 (SD2) Measure CI) Treatment Mittal, N., Low Excellent Lower 21 to 60 Diagnosed by Dermotaxis 25 60.00% Loop suture 25 80.00% RR 0.75(0.52,1.09) Not 2017 Quality (approximation limbs years old; clinical (two parallel (involves Significant achieved) closed examination wires passed using (P- fracture; through dermis corrugated value>.05) trauma; lower and drains and extremity interconnected Ethilon (no. 1) by compression suture) device) Zannis, J., Low Grafting/closure Lower 708 wounds; NP device Vacuum- 370 17.30% Conventional 196 44.39% RR 0.39(0.30,0.51) Treatment 2009 Quality by secondary limbs mean age Assisted normal saline 1 attempt (lower 40.26yrs; Closure device soaked Significant limb) causes dressings (P- include value<.05) MVC, IV infiltration, and trauma Zannis, J., Low Grafting/closure Upper 708 wounds; NP device Vacuum- 68 42.65% Conventional 74 63.51% RR 0.67(0.49,0.93) Treatment 2009 Quality by secondary limbs mean age Assisted normal saline 1 attempt (upper 40.26yrs; Closure device soaked Significant limb) causes dressings (P- include value<.05) MVC, IV infiltration, and trauma Li, W., Moderate Complications Upper/ Osteofascial Diagnosed by Negative 26 0.00% Oil gauze and 26 0.00% RD 0.00(0.00,0.00) Not 2015 Quality (Local or Lower compartment clinical pressure thick dressing; Significant systemic) limbs syndrome; symptoms drainage; operative (P- trauma; 27 (pain, operative decompression value>.05) upper, 25 swelling, decompression lower; all stretch pain, adults circulation disturbance) Li, W., Moderate Days in hospital Upper/ Osteofascial Diagnosed by Negative 26 11.8(3.60) Oil gauze and 26 26.2(5.40) MeanDif -14.4(-16.89,- Treatment 2015 Quality Lower compartment clinical pressure thick dressing; 11.91) 1 limbs syndrome; symptoms drainage; operative Significant trauma; 27 (pain, operative decompression (P- upper, 25 swelling, decompression value<.05) lower; all stretch pain, adults circulation disturbance)

60 Treatment Treatment Result Reference Outcome Affected Patient 1 Mean1/P1 2 Mean2/P2 Effect (95% Favored Title Quality Details Limbs Details Methods (Details) N1 (SD1) (Details) N2 (SD2) Measure CI) Treatment Li, W., Moderate Days until wound Upper/ Osteofascial Diagnosed by Negative 26 9(2.20) Oil gauze and 26 14.2(5.00) MeanDif -5.2(-7.30,-3.10) Treatment 2015 Quality closure Lower compartment clinical pressure thick dressing; 1 limbs syndrome; symptoms drainage; operative Significant trauma; 27 (pain, operative decompression (P- upper, 25 swelling, decompression value<.05) lower; all stretch pain, adults circulation disturbance)

PAIN MANAGEMENT EFFECTS ON DIAGNOSIS

RATIONALE As there is no objective, gold standard for the diagnosis of acute compartment syndrome, the clinician should seek an aggregate of data points (including physical examination findings, escalating need for pain medication, pain out of proportion of injury, perfusion pressure, absolute pressure). At the present, in the absence of adequate studies, we believe that the risk of neuraxial anesthesia delaying and/or masking signs/symptoms associated with impending compartment syndrome (including physical examination findings, need for pain medication, magnitude of pain) outweighs the potential benefits of this treatment modality in high risk patient populations. We acknowledge that this opinion is made in the setting of only isolated extremely low-quality case reports and case series, none of which meet standards for inclusion in this analysis. The current literature suggests both that regional anesthesia may delay diagnosis of acute compartment syndrome and that regional anesthesia does not mask timely diagnosis. If neuraxial anesthesia is administered, we recommend that more emphasis is placed on intracompartmental pressure monitoring as well as break through pain despite regional anesthesia.

Furthermore, we believe that clinicians should be attentive to quantity of narcotic pain medications administered to patients as an indicator of impending acute compartment syndrome.

POSSIBLE HARMS OF IMPLEMENTATION Both delayed diagnosis of acute compartment syndrome and the increased utilization of narcotic pain medication increase risk for adverse outcomes. Excessive and prolonged narcotic use can lead to substantial patient harm however, there may be a role for neuraxial anesthesia to decrease acute narcotic use and, potentially, subsequent dependence. In patients with severe cardiopulmonary disease general anesthesia may carry substantially increased risk of anesthesia- associated complication – in this setting clinicians and patients must carefully weigh the risk/benefit ratio of neuraxial anesthesia versus general anesthesia.

FUTURE RESEARCH High quality studies are needed to assess the ability to diagnose acute compartment syndrome in the setting of regional anesthesia. Similar to the obtunded patient, patients who may benefit from neuraxial anesthesia would benefit from improved monitoring for compartment syndrome. Further studies are also needed evaluate the relationship between regional anesthesia and the development of chronic pain/chronic opioid use.

62 APPENDICES

63 APPENDIX I – REFERENCES FOR INCLUDED LITERATURE

1. Alamshah, S. M., Jahanshahi, A., Minaee, H., Nahidi, A., Dorestan, N., Kabiri, A., Sadat, S. A. Investigating correlation of lower extremity muscle compartment syndrome with muscle related serum enzyme tests: Is any reliable biomarker?. Biomedical and Pharmacology Journal 2016; 3: 1183-1188 2. Bible, J. E., McClure, D. J., Mir, H. R. Analysis of single-incision versus dual-incision fasciotomy for tibial fractures with acute compartment syndrome. Journal of Orthopaedic Trauma 2013; 11: 607-11 3. Cancio, L. C., Jimenez-Reyna, J. F., Barillo, D. J., Walker, S. C., McManus, A. T., Vaughan, G. M. One hundred ninety-five cases of high-voltage electric injury. Journal of Burn Care & Rehabilitation 2005; 4: 331-40 4. Dickson, K. F., Sullivan, M. J., Steinberg, B., Myers, L., Anderson, E. R., 3rd, Harris, M. Noninvasive measurement of compartment syndrome. Orthopedics 2003; 12: 1215-8 5. Heemskerk, J., Kitslaar, P. Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies. World Journal of Surgery 2003; 6: 744-7 6. Jang, Y. S., Lee, B. H., Park, H. S. Lower amputation rate after fasciotomy by straight midline incision technique for a 22,900-V electrical injury to the upper extremities. Injury 2017; 11: 2590-2596 7. Janzing, H. M., Broos, P. L. Routine monitoring of compartment pressure in patients with tibial fractures: Beware of overtreatment! Injury 2001; 5: 415-21 8. Kanj, W. W., Gunderson, M. A., Carrigan, R. B., Sankar, W. N. Acute compartment syndrome of the upper extremity in children: diagnosis, management, and outcomes. Journal of Childrens Orthopaedics 2013; 3: 225-33 9. Kim, T. H., Chung, J. Y., Kim, K. S., Song, H. K. Is external fixation needed for the treatment of tibial fractures with acute compartment syndrome? Injury 2017; 0: 10. Krticka, M., Ira, D., Bilik, A., Rotschein, P., Svancara, J. Fasciotomy closure using negative pressure wound therapy in lower leg compartment syndrome. Bratislavske Lekarske Listy 2016; 12: 710-714 11. Li, W., Ji, L., Tao, W. Effect of vacuum sealing drainage in osteofascial compartment syndrome. International Journal of Clinical and Experimental Medicine 2015; 9: 16112- 16116 12. McQueen, M. M., Christie, J., Court-Brown, C. M. Acute compartment syndrome in tibial diaphyseal fractures. Journal of Bone & Joint Surgery - British Volume 1996; 1: 95-8 13. McQueen, M. M., Duckworth, A. D., Aitken, S. A., Court-Brown, C. M. The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. Journal of Bone & Joint Surgery - American Volume 2013; 8: 673-7 14. Mitas, P., Vejrazka, M., Hruby, J., Spunda, R., Pecha, O., Lindner, J., Spacek, M. Prediction of compartment syndrome based on analysis of biochemical parameters. Annals of Vascular Surgery 2014; 1: 170-7 15. Mittal, N., Bohat, R., Virk, J. S., Mittal, P. Dermotaxis v/s loop suture technique for closure of fasciotomy wounds: a study of 50 cases. Strategies in Trauma and Limb Reconstruction 2017; 0: 1-7

64 16. Mubarak, S. J., Owen, C. A., Hargens, A. R., Garetto, L. P., Akeson, W. H. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. Journal of Bone & Joint Surgery - American Volume 1978; 8: 1091-5 17. Park, S., Ahn, J., Gee, A. O., Kuntz, A. F., Esterhai, J. L. Compartment syndrome in tibial fractures. Journal of Orthopaedic Trauma 2009; 7: 514-8 18. Sangwan, S. S., Marya, K. M., Devgan, A., Siwach, R. C., Kundu, Z. S., Gupta, P. K. Critical evaluation of compartment pressure measurement by saline manometer in peripheral hospital setup. Tropical Doctor 2003; 2: 100-3 19. Thakur, N. A., McDonnell, M., Got, C. J., Arcand, N., Spratt, K. F., DiGiovanni, C. W. Injury patterns causing isolated foot compartment syndrome. Journal of Bone & Joint Surgery - American Volume 2012; 11: 1030-5 20. Zannis, J., Angobaldo, J., Marks, M., DeFranzo, A., David, L., Molnar, J., Argenta, L. Comparison of fasciotomy wound closures using traditional dressing changes and the vacuum-assisted closure device. Annals of Plastic Surgery 2009; 4: 407-9

APPENDIX II – EXCLUDED LITERATURE Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Driscoll, E. B. S.; Maleki, Regional anesthesia or 2016 Local and Regional PICO 1: Serum systematic review A. H.; Jahromi, L.; patient-controlled analgesia Anesthesia Biomarkers Hermecz, B. N.; Nelson, and compartment syndrome L. E.; Vetter, I. L.; in orthopedic surgical Evenhuis, S.; procedures: A systematic Riesenberg, L. A. review Goaley, T. J., Jr.; Can secondary extremity 2007 American Journal of PICO 1: Serum insufficient data for Wyrzykowski, A. D.; compartment syndrome be Surgery Biomarkers target comparison; 17 MacLeod, J. B.; Wise, K. diagnosed earlier? ACS pts B.; Dente, C. J.; Salomone, J. P.; Nicholas, J. M.; Vercruysse, G. A.; Ingram, W. L.; Rozycki, G. S.; Feliciano, D. V. Hayakawa, H.; Aldington, Acute traumatic compartment 2009 Trauma PICO 1: Serum systematic review D. J.; Moore, R. A. syndrome: A systematic Biomarkers review of results of fasciotomy Hsueh, Y. Y.; Chen, C. Analysis of factors influencing 2011 Burns PICO 1: Serum Insufficient data for L.; Pan, S. C. limb amputation in high- Biomarkers target condition; 4 CS voltage electrically injured patients Ihedioha, U.; Sinha, S.; Do creatine kinase (CK) levels 2005 Scottish Medical PICO 1: Serum <20 patients; n15 Campbell, A. C. influence the diagnosis or Journal Biomarkers outcome in patients with compartment syndrome? Koubar, S. H.; Estrella, Rhabdomyolysis in an HIV 2017 BMC Nephrology PICO 1: Serum pico not answered M. M.; Warrier, R.; cohort: Epidemiology, causes Biomarkers Moore, R. D.; Lucas, G. and outcomes M.; Atta, M. G.; Fine, D. M. Lai, D. T. M.; Ingvar, C.; The value of monitoring 1993 Regional Cancer PICO 1: Serum insufficient data for Thompson, J. F. serum creatine Treatment Biomarkers target condition; 5 phosphokinase following fasciotomies

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion hyperthermic isolated limb perfusion for melanoma

O'Connor, A. D.; Padilla- Prevalence of 2015 Journal of Medical PICO 1: Serum pico not answered; Jones, A.; Gerkin, R. D.; Rhabdomyolysis in Toxicology: Official Biomarkers CS outcome Levine, M. Sympathomimetic Toxicity: a Journal of the Comparison of Stimulants American College of Medical Toxicology Ulmer, T. The clinical diagnosis of 2002 Journal of PICO 1: Serum systematic review compartment syndrome of the Orthopaedic Trauma Biomarkers lower leg: are clinical findings predictive of the disorder? Valdez, C.; Schroeder, Serum creatine kinase levels 2013 The Journal of PICO 1: Serum not best available E.; Amdur, R.; Pascual, are associated with extremity Trauma and Acute Biomarkers evidence J.; Sarani, B. compartment syndrome Care Surgery Vrouenraets, B. C.; Value of laboratory tests in 1997 Annals of Surgical PICO 1: Serum insufficient data for Kroon, B. B.; Klaase, J. monitoring acute regional Oncology Biomarkers target comparison; n6 M.; Bonfrer, J. M.; toxicity after isolated limb ACS pts Nieweg, O. E.; van perfusion Slooten, G. W.; van Dongen, J. A. de Franciscis, S.; De Biomarkers in post- 2016 International Wound PICO 1: Serum insufficient data for Caridi, G.; Massara, M.; reperfusion syndrome after Journal Biomarkers; PICO 10: target condition; 7 CS Spinelli, F.; Gallelli, L.; acute lower limb ischaemia Fasciotomy Methods Buffone, G.; Calio, F. G.; Butrico, L.; Grande, R.; Serra, R. Hsu, C. P.; Chuang, J. Predictors of the development 2015 Scandinavian PICO 1: Serum pico not answered; F.; Hsu, Y. P.; Wang, S. of post-snakebite Journal of Trauma, Biomarkers; PICO 13: snakebite risk Y.; Fu, C. Y.; Yuan, K. compartment syndrome Resuscitation & Associative Fracture C.; Chen, C. H.; Kang, S. Emergency Medicine C.; Liao, C. H. Lang, E. K. Streptokinase therapy: 1985 Radiology PICO 1: Serum insufficient data for Complications of intra-arterial Biomarkers; PICO 13: target condition; 9 use Associative Fracture fasciotomies

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion NystrÃ¶m Wendt, A.; Myoglobin does not predict 2017 International Journal PICO 1: Serum Insufficient data for Mattsson, J.; Olofsson local toxicity in isolated limb of Hyperthermia Biomarkers; PICO 8: target condition Bagge, R. perfusion Physical Exam Awake Tsai, W. H.; Huang, S. High risk of rhabdomyolysis 2015 Annals of Plastic PICO 3: Fasciotomy risk assessment; no tx T.; Liu, W. C.; Chen, L. and acute kidney injury after Surgery Missed ACS W.; Yang, K. C.; Hsu, K. traumatic limb compartment C.; Lin, C. T.; Ho, Y. Y. syndrome Adeyeye, A. I.; Esan, O.; Assessment of normal 2017 European Journal of PICO 4: Pressure Insufficient data for Ikem, I. C. forearm compartment Trauma & Monitoring target condition; no pressures in a Nigerian Emergency Surgery ACS population Al-Dadah, O. Q.; Darrah, Continuous compartment 2008 Injury PICO 4: Pressure not best available C.; Cooper, A.; Donell, S. pressure monitoring vs. Monitoring evidence T.; Patel, A. D. clinical monitoring in tibial diaphyseal fractures Allen, M. J.; Stirling, A. Intracompartmental pressure 1985 Journal of Bone and PICO 4: Pressure insufficient data for J.; Crawshaw, C. V.; monitoring of leg injuries. An Joint Surgery - Monitoring target condition Barnes, M. R. aid to management Series B Amendola, A.; Faber, K.; Compartment pressure 1999 Arthroscopy PICO 4: Pressure insufficient data for Willits, K.; Miniaci, A.; monitoring during anterior Monitoring target condition; no Labib, S.; Fowler, P. cruciate ligament ACS reconstruction Ashton, H. The effect of increased tissue 1975 Clinical PICO 4: Pressure review pressure on blood flow Orthopaedics & Monitoring Related Research Brooker, A. F., Jr.; Tissue pressure to evaluate 1979 Journal of Trauma- PICO 4: Pressure insufficient data for Pezeshki, C. compartmental syndrome Injury Infection & Monitoring target condition; 5 Critical Care fasciotomies Carbonell, P. G.; Prats, Monitoring antebrachial 2004 Journal of Pediatric PICO 4: Pressure insufficient data; 1 CS F. L.; Fernandez, P. D.; compartmental pressure in Orthopaedics, Part B Monitoring pt Valiente Valero, J. M.; displaced supracondylar Sastre, S. elbow fractures in children Clasbrummel, B.; Muhr, Pressure sensors for the 2004 Minimally Invasive PICO 4: Pressure review G.; MÃ¶llenhoff, G. monitoring of diseases in Therapy and Allied Monitoring surgical care Technologies

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Donahue, P.; Wheeler, A method for rapid 1992 West Virginia PICO 4: Pressure review W. E. intracompartmental pressure Medical Journal Monitoring measurement Dragas, M.; Davidovic, Upper extremity arterial 2009 Injury PICO 4: Pressure Insufficient data for L.; Kostic, D.; Markovic, injuries: Factors influencing Monitoring target comparison M.; Pejkic, S.; Ille, T.; Ilic, treatment outcome N.; Koncar, I. Dresing, K.; Peterson, T.; Compartment pressure in the 1994 Archives of PICO 4: Pressure insufficient data; 2 CS Schmit-Neuerburg, K. P. carpal tunnel in distal Orthopaedic & Monitoring pts fractures of the radius. A Trauma Surgery prospective study Gelberman, R. H.; Tissue pressure threshold for 1983 Clinical PICO 4: Pressure all healthy pts Szabo, R. M.; peripheral nerve viability Orthopaedics & Monitoring Williamson, R. V.; Related Research Hargens, A. R.; Yaru, N. C.; Minteer-Convery, M. A. Harris, I. A.; Kadir, A.; Continuous compartment 2006 Journal of Trauma- PICO 4: Pressure insufficient data for Donald, G. pressure monitoring for tibia Injury Infection & Monitoring condition; 6 CS pts fractures: does it influence Critical Care outcome? Harris, Ia; Kadir, A; Continuous compartment 2006 Journal of trauma PICO 4: Pressure insufficient data for Donald, G pressure monitoring for tibia Monitoring target condition; 5 CS fractures: does it influence outcome? Hoffmann, M.; Spontaneous and non- 2014 Langenbecks PICO 4: Pressure insufficient data for Zimmermann, M.; Meyer, spontaneous bleeding Archives of Surgery Monitoring target comparison R.; Laubert, T.; Begum, complications in patients with N.; Keck, T.; Kujath, P.; oral vitamin K antagonist Schloericke, E. therapy Jerosch, J.; Castro, W. Intracompartmental pressure 1991 Acta Orthopaedica PICO 4: Pressure irrelevant topic; H.; Geske, B. in the lower extremity after Belgica Monitoring pressure no ACS arthroscopic surgery Kiaer, T.; Kristensen, K. Intracompartmental pressure, 1988 Archives of PICO 4: Pressure <20 patients; 10 D. PO2, PCO2 and blood flow in Orthopaedic & Monitoring healthy the human skeletal muscle Traumatic Surgery

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Kierzynka, G.; Grala, P. Compartment syndrome of 2008 Ortopedia PICO 4: Pressure case control; 13 pts the foot after calcaneal Traumatologia Monitoring with control limbs fractures Rehabilitacja Larson, M.; Leigh, J.; Detecting compartmental 1986 Focus on Critical PICO 4: Pressure review Wilson, L. R. syndrome using continuous Care Monitoring pressure monitoring Luks, F. I. An easy approach to the slit 1988 Surgery, Gynecology PICO 4: Pressure review catheter technique in & Obstetrics Monitoring intracompartmental pressure measurement Lynch, J. E.; Lynch, J. Noninvasive monitoring of 2009 Journal of PICO 4: Pressure all healthy pts; no K.; Cole, S. L.; Carter, J. elevated intramuscular Orthopaedic Monitoring pressure thresholds A.; Hargens, A. R. pressure in a model Research compartment syndrome via quantitative fascial motion Matsen, F. A., 3rd; Mayo, A model compartmental 1977 Journal of Bone & PICO 4: Pressure model study K. A.; Krugmire, R. B., syndrome in man with Joint Surgery - Monitoring Jr.; Sheridan, G. W.; particular reference to the American Volume Kraft, G. H. quantification of nerve function McDermott, A. G.; Monitoring acute 1984 Clinical PICO 4: Pressure Non-human and Marble, A. E.; Yabsley, compartment pressures with Orthopaedics & Monitoring healthy volunteers R. H. the S.T.I.C. catheter Related Research McDougall, C. G.; A new technique of catheter 1991 Journal of Trauma- PICO 4: Pressure review Johnston, G. H. placement for measurement Injury Infection & Monitoring of forearm compartment Critical Care pressures Moehring, H. D.; Compartment pressure 1995 Orthopedics PICO 4: Pressure Insufficient data for Voigtlander, J. P. monitoring during Monitoring target condition; 9 CS intramedullary fixation of tibial fractures Mok, J. M.; Hansen, E. Diagnosis of acute 2012 Techniques in PICO 4: Pressure <20 patients; n16 N.; Kang, H.; Kandemir, compartment syndrome: Orthopaedics Monitoring U. Direct measurement of tissue oxygenation

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Mubarak, S. J.; Hargens, The wick catheter technique 1976 Journal of Bone & PICO 4: Pressure animal study; dog A. R.; Owen, C. A.; for measurement of Joint Surgery - Monitoring Garetto, L. P.; Akeson, intramuscular pressure. A American Volume W. H. new research and clinical tool Myerson, M. S.; Juliano, The use of a pneumatic 2000 Military Medicine PICO 4: Pressure insufficient data; 0 CS P. J.; Koman, J. D. intermittent impulse Monitoring pts compression device in the treatment of calcaneus fractures Ogunlusi, J. D.; Oginni, Normal leg compartment 2005 Iowa Orthopaedic PICO 4: Pressure pico questions not L. M.; Ikem, I. C. pressures in adult Nigerians Journal Monitoring answered; no ACS using the Whitesides method Ogunlusi, J. D.; Oginni, Compartmental pressure in 2005 International PICO 4: Pressure insufficient data; 3 CS L. M.; Ikem, I. C. adults with tibial Orthopaedics Monitoring pts fracture.[Erratum appears in Int Orthop. 2005 Jun;29(3):199] Ogunlusi, J. D.; Oginni, Compartmental pressure in 2005 International PICO 4: Pressure insufficient data; 3 CS L. M.; Ikem, I. C. adults with tibial fracture Orthopaedics Monitoring pts Olivecrona, C.; Lapidus, Tourniquet time affects 2013 International PICO 4: Pressure insufficient data; 2 CS L. J.; Benson, L.; postoperative complications Orthopaedics Monitoring pts Blomfeldt, R. after knee arthroplasty O'Toole, R. V.; Whitney, Variation in diagnosis of 2009 Journal of Trauma- PICO 4: Pressure insufficient data for A.; Merchant, N.; Hui, E.; compartment syndrome by Injury Infection & Monitoring target comparison Higgins, J.; Kim, T. T.; surgeons treating tibial shaft Critical Care Sagebien, C. fractures Paletta, C. E.; Dehghan, Compartment syndrome in 1994 Annals of Plastic PICO 4: Pressure Insufficient data for K. children Surgery Monitoring target comparison Petrisor, B.; Anderson, Infection after reamed 2005 Journal of PICO 4: Pressure Insufficient data for S.; Court-Brown, C. M. intramedullary nailing of the Orthopaedic Trauma Monitoring target comparison tibia: A case series review Pradka, L. Use of the wick catheter for 1985 Orthopaedic Nursing PICO 4: Pressure review diagnosing and monitoring Monitoring compartment syndrome

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Ramprasath, D. R.; Effectiveness of Serial 2016 Malaysian PICO 4: Pressure Insufficient data for Thirunarayanan, V.; Measurement of Differential Orthopaedic Journal Monitoring target condition; 2 David, J.; Anbazhagan, Pressure in Closed Tibial ACS S. Diaphyseal Fractures in Diagnosing Acute Compartment Syndrome using Whiteside's Technique Russell, W. L.; Apyan, P. Use of wick catheter 1985 Journal of the PICO 4: Pressure case reports M. compartment measurements Tennessee Medical Monitoring in the vascular trauma patient Association Russell, W. L.; Apyan, P. An electronic technique for 1985 Surgery, Gynecology PICO 4: Pressure summary M.; Burns, R. P. compartment pressure & Obstetrics Monitoring measurement using the wick catheter Russell, W. L.; Apyan, P. Utilization and wide clinical 1985 Surgery, Gynecology PICO 4: Pressure confounded M.; Burns, R. P. implementation using the wick & Obstetrics Monitoring population for catheter for compartment diagnostic pressure measurement comparison Shadgan, B.; Menon, M.; Diagnostic techniques in 2008 Journal of PICO 4: Pressure review O'Brien, P. J.; Reid, W. acute compartment syndrome Orthopaedic Trauma Monitoring D. of the leg Shah, D. M.; Bock, D. E.; Beneficial effects of 1996 Cardiovascular PICO 4: Pressure insufficient data for Darling, R. C., 3rd; hypertonic mannitol in acute Surgery Monitoring target condition Chang, B. B.; Kupinski, ischemia--reperfusion injuries A. M.; Leather, R. P. in humans Shakespeare, D. T.; Compartmental pressure 1982 Journal of Bone & PICO 4: Pressure <20 patients; n5 Henderson, N. J. changes during calcaneal Joint Surgery - Monitoring traction in tibial fractures British Volume Shuler, M. S.; Reisman, Correlation between muscle 2010 Journal of Bone & PICO 4: Pressure case control; 14 pts W. M.; Kinsey, T. L.; oxygenation and Joint Surgery - Monitoring with control limbs Whitesides, T. E., Jr.; compartment pressures in American Volume Hammerberg, E. M.; acute compartment syndrome Davila, M. G.; Moore, T. of the leg J.

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Steinberg, B.; Riel, R.; Quantitative muscle hardness 2011 Physiological PICO 4: Pressure healthy participants Armitage, M.; Berrey, H. as a noninvasive means for Measurement Monitoring detecting patients at risk of compartment syndromes Tharakan, S. J.; Subotic, Compartment Pressures in 2016 Journal of Pediatric PICO 4: Pressure pico not answered; no U.; Kalisch, M.; Staubli, Children With Normal and Orthopedics Monitoring CS G.; Weber, D. M. Fractured Forearms: A Preliminary Report Tian, S.; Lu, Y.; Liu, J.; Comparison of 2 available 2016 American Journal of PICO 4: Pressure animal study; rabbits Zhu, Y.; Cui, Y.; Lu, J. methods with Bland-Altman Emergency Medicine Monitoring vs healthy humans analysis for measuring intracompartmental pressure Triffitt, P. D.; Konig, D.; Compartment pressures after 1992 Journal of Bone and PICO 4: Pressure insufficient data; 0 CS Harper, W. M.; Barnes, closed tibial shaft fracture. Joint Surgery - Monitoring pts M. R.; Allen, M. J.; Their relation to functional Series B Gregg, P. J. outcome Turnbull, D.; Farid, A.; Calf compartment pressures 2002 Anaesthesia PICO 4: Pressure pico not answered; no Hutchinson, S.; in the Lloyd-Davies position: a Monitoring CS Shorthouse, A.; Mills, G. cause for concern? H. Uppal, G. S.; Smith, R. Accurate compartment 1992 Journal of PICO 4: Pressure insufficient data for C.; Sherk, H. H.; Mooar, pressure measurement using Orthopaedic Trauma Monitoring diagnostic P. the Intervenous Alarm Control comparison (IVAC) Pump. Report of a technique Vaillancourt, C.; Shrier, Acute compartment 2004 CJEM Canadian PICO 4: Pressure Insufficient data for I.; Vandal, A.; Falk, M.; syndrome: how long before Journal of Monitoring target comparison Rossignol, M.; Vernec, muscle necrosis Emergency Medical A.; Somogyi, D. occurs?.[Erratum appears in Care CJEM. 2004 July;6(4):239] White, T. O.; Howell, G. Elevated intramuscular 2003 Journal of Trauma- PICO 4: Pressure insufficient data for E.; Will, E. M.; Court- compartment pressures do Injury Infection & Monitoring target comparison Brown, C. M.; McQueen, not influence outcome after Critical Care M. M. tibial fracture Whitesides Jr, T. E.; A simple method for tissue 1975 Archives of Surgery PICO 4: Pressure case report Haney, T. C.; Harada, H. pressure determination Monitoring

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Whitney, A.; O'Toole, R. Do one-time 2014 The Journal of PICO 4: Pressure no ACS pts V.; Hui, E.; Sciadini, M. intracompartmental pressure Trauma and Acute Monitoring F.; Pollak, A. N.; measurements have a high Care Surgery Manson, T. T.; Eglseder, false-positive rate in W. A.; Andersen, R. C.; diagnosing compartment Lebrun, C.; Doro, C.; syndrome? Nascone, J. W. Wilson, S. C.; Vrahas, M. A simple method to measure 1997 Orthopedics PICO 4: Pressure no mention of patients S.; Berson, L.; Paul, E. compartment pressures using Monitoring M. an intravenous catheter Wind, T. C.; Saunders, Compartment syndrome after 2012 Journal of PICO 4: Pressure insufficient data for S. M.; Barfield, W. R.; low-energy tibia fractures Orthopaedic Trauma Monitoring target comparison Mooney, J. F., 3rd; sustained during athletic Hartsock, L. A. competition Acklin, Y. P.; Potocnik, Compartment syndrome in 2012 Archives of PICO 4: Pressure insufficient data for P.; Sommer, C. dislocation and non- Orthopaedic & Monitoring; PICO 10: target comparison dislocation type proximal tibia Trauma Surgery Fasciotomy Methods outcome fractures: analysis of 356 consecutive cases Fukuda, I.; Chiyoya, M.; Acute limb ischemia: 2015 General Thoracic PICO 4: Pressure review Taniguchi, S.; Fukuda, contemporary approach and Cardiovascular Monitoring; PICO 10: W. Surgery Fasciotomy Methods Goyal, S.; Naik, M. A.; Functional outcome of tibial 2017 World Journal of PICO 4: Pressure insufficient data for Tripathy, S. K.; Rao, S. fracture with acute Orthopedics Monitoring; PICO 10: target outcomes K. compartment syndrome and Fasciotomy Methods correlation to deep posterior compartment pressure Koman, L. A.; Hardaker, Wick catheter in evaluating 1981 Southern Medical PICO 4: Pressure Insufficient data for W. T., Jr.; Goldner, J. L. and treating compartment Journal Monitoring; PICO 10: diagnostic syndromes Fasciotomy Methods comparison Mars, M.; Hadley, G. P. Raised compartmental 1998 Injury PICO 4: Pressure Insufficient data for pressure in children: a basis Monitoring; PICO 10: target condition; n9 for management Fasciotomy Methods

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Matsen, F. A., 3rd Compartmental syndrome. An 1975 Clinical PICO 4: Pressure review unified concept Orthopaedics & Monitoring; PICO 10: Related Research Fasciotomy Methods Sullivan, C. M.; Mubarak, Diagnosis and treatment of 1989 Techniques in PICO 4: Pressure review S. J. upper extremity compartment Orthopaedics Monitoring; PICO 10: syndrome Fasciotomy Methods Frink, M.; Klaus, A. K.; Long term results of 2007 Injury PICO 4: Pressure insufficient data for Kuther, G.; Probst, C.; compartment syndrome of the Monitoring; PICO 10: target comparison Gosling, T.; Kobbe, P.; lower limb in polytraumatised Fasciotomy Methods; Hildebrand, F.; Richter, patients PICO 13: Associative M.; Giannoudis, P. V.; Fracture; PICO 12: Krettek, C.; Pape, H. C. Wound Management

Matsen, F. A., 3rd; Mayo, Continuous monitoring of 1977 Bibliotheca PICO 4: Pressure animal study K. A.; Sheridan, G. W.; intramuscular pressure and its Anatomica Monitoring; PICO 11: Pre- Krugmire, R. B., Jr. application to clinical op Adjunctive Therapy compartmental syndromes Turkmen, A.; Temel, M. Algorithmic approach to the 2016 Injury PICO 4: Pressure insufficient data for prevention of unnecessary Monitoring; PICO 11: Pre- target condition; 3 fasciotomy in extremity snake op Adjunctive Therapy ACS bite Halpern, A. A.; Nagel, D. Anterior compartment 1980 Journal of Trauma- PICO 4: Pressure no diagnosis of ACS A. pressures in patients with Injury Infection & Monitoring; PICO 13: tibial fractures Critical Care Associative Fracture Kinner, B.; Tietz, S.; Outcome after complex 2011 Journal of Trauma - PICO 4: Pressure Insufficient data for MÃ¼ller, F.; Prantl, L.; trauma of the foot Injury, Infection and Monitoring; PICO 13: target comparison Nerlich, M.; Roll, C. Critical Care Associative Fracture Ozkayin, N.; Aktuglu, K. Absolute compartment 2005 International PICO 4: Pressure insufficient data for pressure versus differential Orthopaedics Monitoring; PICO 13: target condition pressure for the diagnosis of Associative Fracture compartment syndrome in tibial fractures

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Kosir, R.; Moore, F. A.; Acute lower extremity 2007 Journal of Trauma- PICO 4: Pressure Insufficient data for Selby, J. H.; Cocanour, compartment syndrome Injury Infection & Monitoring; PICO 8: target condition; 9 C. S.; Kozar, R. A.; (ALECS) screening protocol Critical Care Physical Exam Awake ACS Gonzalez, E. A.; Todd, in critically ill trauma patients S. R. Tornetta, P., 3rd; Compartment Syndrome of 2016 Journal of PICO 4: Pressure <10 pts per Puskas, B. L.; Wang, K. the Leg Associated With Orthopaedic Trauma Monitoring; PICO 8: comparison group Fracture: An Algorithm to Physical Exam Awake Avoid Releasing the Posterior Compartments Willey, R. F.; Corall, R. Non-invasive method for the 1982 Lancet PICO 4: Pressure <20 patients; n7 J.; French, E. B. measurement of anterior tibial Monitoring; PICO 8: compartment pressure Physical Exam Awake Livingston, K.; Pediatric Nonfracture Acute 2016 Journal of Pediatric PICO 4: Pressure Insufficient data for Glotzbecker, M.; Miller, Compartment Syndrome: A Orthopedics Monitoring; PICO 8: target condition; P. E.; Hresko, M. T.; Review of 39 Cases Physical Exam Awake; Hedequist, D.; Shore, B. PICO 10: Fasciotomy J. Methods

McQueen, M. M.; Predictors of Compartment 2015 Journal of PICO 4: Pressure not best available Duckworth, A. D.; Aitken, Syndrome After Tibial Orthopaedic Trauma Monitoring; PICO 8: evidence S. A.; Sharma, R. A.; Fracture Physical Exam Awake; Court-Brown, C. M. PICO 13: Associative Fracture

Collinge, C.; Kuper, M. Comparison of three methods 2010 Journal of PICO 6: Pressure insufficient data for for measuring Orthopaedic Trauma Methods diagnostic intracompartmental pressure comparison in injured limbs of trauma patients Hammerberg, E. M.; The reliability of measurement 2012 Journal of PICO 6: Pressure Non-human; bovine Whitesides Jr, T. E.; of tissue pressure in Orthopaedic Trauma Methods model Seiler, Iii J. G. compartment syndrome Staudt, J. M.; Smeulders, Normal compartment 2008 Journal of Bone & PICO 6: Pressure all healthy pts M. J.; van der Horst, C. pressures of the lower leg in Joint Surgery - Methods M. children British Volume

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Willy, C.; Gerngross, H.; Measurement of 1999 Journal of Bone & PICO 6: Pressure not best available Sterk, J. intracompartmental pressure Joint Surgery - Methods evidence with use of a new electronic American Volume transducer-tipped catheter system Ziv, I.; Zeligowski, A. A.; Immediate care of crush 1990 Clinical PICO 6: Pressure insufficient data for Elyashuv, O.; Mosheiff, injuries and compartment Orthopaedics & Methods target comparison R.; Lilling, M.; Segal, D. syndromes with the split- Related Research thickness skin excision Ball, C. G.; Kirkpatrick, Renal allograft compartment 2006 American Journal of PICO 7: Alternative Non-extremity; A. W.; Yilmaz, S.; syndrome: an Surgery Diagnosis abdomen Monroy, M.; Nicolaou, S.; underappreciated Salazar, A. postoperative complication Barrow, A. E.; Sheean, Return to duty following 2017 Injury PICO 7: Alternative Insufficient data for A. J.; Burns, T. C. combat-related multi- Diagnosis target condition ligamentous knee injury Feldberg, M. A.; Koehler, Psoas compartment disease 1983 Radiology PICO 7: Alternative irrelevant topic; P. R.; van Waes, P. F. studied by computed Diagnosis abscesses tomography. Analysis of 50 cases and subject review Giannotti, G.; Cohn, S. Utility of near-infrared 2000 Journal of Trauma- PICO 7: Alternative insufficient data for M.; Brown, M.; Varela, J. spectroscopy in the diagnosis Injury Infection & Diagnosis target outcomes; 9 E.; McKenney, M. G.; of lower extremity Critical Care CS Wiseberg, J. A. compartment syndrome Haaverstad, R.; Nilsen, The use of MRI in the 1992 European Journal of PICO 7: Alternative insufficient data for G.; Myhre, H. O.; investigation of leg oedema Vascular Surgery Diagnosis target condition; 2 CS Saether, O. D.; Rinck, P. A. Kim, D. J.; Cho, Y. J.; Near-Infrared Spectroscopy 2017 ASAIO Journal PICO 7: Alternative Insufficient data for Park, S. H.; Lim, C.; Monitoring for Early Detection Diagnosis target condition; 5 CS Park, K. H.; Jheon, S. H.; of Limb Ischemia in Patients Kim, J. S. on Veno-Arterial Extracorporeal Membrane Oxygenation

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Leaming, D. B.; Casey, Anterior tibial syndrome 1963 Medical Journal of PICO 7: Alternative case report J. H. following aortography and Australia Diagnosis associated with septicaemia Pineton De Chambrun, The Clinical Picture of Severe 2017 Critical Care PICO 7: Alternative Insufficient data for M.; Luyt, C. E.; Beloncle, Systemic Capillary-Leak Medicine Diagnosis target comparison; F.; Gousseff, M.; Mauhin, Syndrome Episodes CS outcome W.; Argaud, L.; Requiring ICU Admission Ledochowski, S.; Moreau, A. S.; Sonneville, R.; VerdiÃ¨re, B.; Merceron, S.; Zappella, N.; Landais, M.; Contou, D.; Demoule, A.; Paulus, S.; Souweine, B.; Lecomte, B.; Vieillard-Baron, A.; Terzi, N.; Azoulay, E.; Friolet, R.; Puidupin, M.; Devaquet, J.; Mazou, J. M.; Fedun, Y.; Mira, J. P.; Raphalen, J. H.; Combes, A.; Amoura, Z. Schmidt, A. Acute compartment 2012 Techniques in PICO 7: Alternative review syndrome: A promising future Orthopaedics Diagnosis for its diagnosis and management Shuler, M. S.; Reisman, Near-infrared spectroscopy in 2009 Journal of Bone & PICO 7: Alternative pico not answered; no W. M.; Whitesides, T. E., lower extremity trauma Joint Surgery - Diagnosis CS Jr.; Kinsey, T. L.; American Volume Hammerberg, E. M.; Davila, M. G.; Moore, T. J. Sutter, M. E.; Venous Ultrasound Testing 2009 Journal of PICO 7: Alternative Insufficient data for Turnipseed, S. D.; for Suspected Thrombosis: Emergency Medicine Diagnosis target condition; 1 CS Diercks, D. B.; Samuel, Incidence of Significant Non- P.; White, R. H. Thrombotic findings

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Topal, A. E.; Eren, M. N.; Management of non-traumatic 2011 International PICO 7: Alternative Insufficient data for Celik, Y. acute limb ischemia and Angiology Diagnosis target comparison predictors of outcome in 270 thrombembolectomy cases Totapally, B. R. Epidemiology and Outcomes 2017 Pediatric Infectious PICO 7: Alternative insufficient data for of Hospitalized Children with Disease Journal Diagnosis target comparison Necrotizing Soft-Tissue Infections Uzun, N.; Kiziltan, M. E.; 1999 Marmara eartquake; 2005 Electromyography PICO 7: Alternative insufficient data for Savrun, F. K. peripheral nerve injuries - and Clinical Diagnosis target comparison Electrophysiologic evaluation Neurophysiology van Gruting, I. M. A.; Imaging modalities for the 2015 Cochrane Database PICO 7: Alternative irrelevant topic; Stankiewicz, A.; Thakar, detection of posterior of Systematic Diagnosis systematic review R.; Inthout, J.; Santoro, compartment disorders in Reviews G. A.; Sultan, A. H. women with obstructed defaecation syndrome Wen, T.; Deibert, C. M.; Positioning-related 2014 Journal of PICO 7: Alternative Insufficient data for Siringo, F. S.; Spencer, complications of minimally Endourology Diagnosis target condition B. A. invasive radical prostatectomies Zohn, D. A.; Leach, R. E. The Role of the 1964 Archives of Physical PICO 7: Alternative case reports Electromyogram in the Medicine & Diagnosis Diagnosis and Management Rehabilitation of Anterior Tibial Compartment Syndrome Schmidt, A. H.; Bosse, Predicting Acute 2017 Journal of PICO 7: Alternative insufficient data for M. J.; Frey, K. P.; Compartment Syndrome Orthopaedic Trauma Diagnosis; PICO 1: target comparison O'Toole, R. V.; Stinner, (PACS): The Role of Serum Biomarkers; PICO D. J.; Scharfstein, D. O.; Continuous Monitoring 4: Pressure Monitoring; Zipunnikov, V.; PICO 8: Physical Exam MacKenzie, E. J.; Metrc, Awake Reisman, W. M.; Shuler, Use of Near-Infrared 2016 Military Medicine PICO 7: Alternative insufficient data for M. S.; Roskosky, M.; Spectroscopy to Detect Diagnosis; PICO 13: target condition; no Kinsey, T. L.; Freedman, Sustained Hyperaemia Associative Fracture CS B. A. Following Lower Extremity Trauma

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Roskosky, M.; Robinson, Subcutaneous depth in a 2014 The Journal of PICO 7: Alternative no patient had ACS G.; Reisman, W.; Ziran, traumatized lower extremity Trauma and Acute Diagnosis; PICO 13: B.; Shuler, M. S.; Care Surgery Associative Fracture Freedman, B. Wang, S. H.; Lin, K. Y.; The thickness of the anterior 2014 Injury PICO 7: Alternative Insufficient data for Yang, J. J.; Chang, J. H.; compartment does not Diagnosis; PICO 4: target condition; no cs Huang, G. S.; Lin, L. C. indicate compartment Pressure Monitoring; syndrome in acutely PICO 6: Pressure traumatised legs? Methods Jones, W. G., 2nd; Perry, Changes in tibial venous 1989 Archives of Surgery PICO 7: Alternative Insufficient data for M. O.; Bush, H. L., Jr. blood flow in the evolving Diagnosis; PICO 6: target condition; 9 CS compartment syndrome Pressure Methods of 26 Leach, R. E.; Zohn, D. Anterior Tibial Compartment 1964 Archives of Surgery PICO 7: Alternative review; case report A.; Stryker, W. S. Syndrome. Clinical and Diagnosis; PICO 8: Electromyographic Aspects Physical Exam Awake Aita, D. J.; Kvamme, P.; Venous insufficiency: a late 1993 American Surgeon PICO 8: Physical Exam Insufficient data for Rice, J. C.; Kerstein, M. sequelae of four-compartment Awake target comparison D. fasciotomy in the lower extremity? Andrews, L. W. Neurovascular assessment 1990 Advancing Clinical PICO 8: Physical Exam review Care Awake Ashurst, J.; Cannon, R. Approach and management 2012 Osteopathic Family PICO 8: Physical Exam review of venomous snake bites: A Physician Awake guide for the primary care physician Baquie, P.; Brukner, P. Injuries presenting to an 1997 Clinical Journal of PICO 8: Physical Exam incidence study Australian sports medicine Sport Medicine Awake centre: A 12-month study

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Bogdan, Y.; Tornetta, Iii Treatment and complications 2014 Journal of PICO 8: Physical Exam Insufficient data for P.; Leighton, R.; Dahn, in orthopaedic trauma Orthopaedic Trauma Awake target condition; 2 CS U.; Sagi, H.; Nalley, C.; patients with symptomatic Sanders, D.; Siegel, J.; pulmonary embolism Mullis, B.; Bemenderfer, T.; Vallier, H.; Boyd, A.; Schmidt, A.; Westberg, J. R.; Egol, K. A.; Kottmeier, S.; Collinge, C. Brukner, P. Pain in the lower leg 1997 Australian Family PICO 8: Physical Exam review Physician Awake Brumback, R. J. Compartment syndrome in 1997 Techniques in PICO 8: Physical Exam review the polytrauma patient Orthopaedics Awake Cambon-Binder, A.; Pulseless supracondylar 2017 International PICO 8: Physical Exam insufficient data for Jehanno, P.; Tribout, L.; humeral fractures in children: Orthopaedics Awake target condition; 1 CS Valenti, P.; Simon, A. L.; vascular complications in a Ilharreborde, B.; Mazda, ten year series K. Cascio, B. M.; Wilckens, Documentation of acute 2005 Journal of Bone & PICO 8: Physical Exam insufficient data for J. H.; Ain, M. C.; compartment syndrome at an Joint Surgery - Awake target comparison Toulson, C.; Frassica, F. academic health-care center American Volume J. Cestero, R. F.; Plurad, Iliac artery injuries and pelvic 2009 Journal of Trauma - PICO 8: Physical Exam Insufficient data for D.; Green, D.; Inaba, K.; fractures: A national trauma Injury, Infection and Awake target comparison Putty, B.; Benfield, R.; database analysis of Critical Care Lam, L.; Talving, P.; associated injuries and Demetriades, D. outcomes Fields, C. E.; Latifi, R.; Brachial and forearm vessel 2002 Surgical Clinics of PICO 8: Physical Exam review Ivatury, R. R. injuries North America Awake Gamulin, A.; Armenter- Conditions found among 2012 Journal of Pediatric PICO 8: Physical Exam Insufficient data for Duran, J.; Assal, M.; pediatric survivors during the Orthopaedics Awake target condition; 4 CS Hagon, O.; Dayer, R. early response to natural disaster: A prospective case study

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Giri, S.; Risnes, K.; Impact of 2015 earthquakes 2018 PLoS ONE PICO 8: Physical Exam insufficient data for Uleberg, O.; Rogne, T.; on a local hospital in Nepal: A Awake target condition; 18 Shrestha, S. K.; Nygaard prospective hospital-based CS Ã?, P.; Koju, R.; study SolligÃ¥rd, E. Guerrero, A.; Gibson, K.; Limb loss following lower 2002 Injury PICO 8: Physical Exam insufficient data for Kralovich, K. A.; Pipinos, extremity arterial trauma: what Awake diagnostic I.; Agnostopolous, P.; can be done proactively? comparison Carter, Y.; Bulger, E.; Meissner, M.; Karmy- Jones, R. Hargens, A. R.; Akeson, Tissue fluid states in 1977 Bibliotheca PICO 8: Physical Exam <20 patients; n16 W. H.; Mubarak, S. J.; compartment syndromes Anatomica Awake Owen, C. A.; Garetto, L. P. Holden, C. E. Compartmental syndromes 1975 Clinical PICO 8: Physical Exam review following trauma Orthopaedics & Awake Related Research Hungerford, D. S. Pathogenetic considerations 1981 Canadian Journal of PICO 8: Physical Exam review in ischemic necrosis of bone Surgery Awake Katz, L. M.; Nauriyal, V.; Infrared imaging of trauma 2008 Critical Care PICO 8: Physical Exam confounded patient Nagaraj, S.; Finch, A.; patients for detection of acute Medicine Awake population Pearlstein, K.; compartment syndrome of the Szymanowski, A.; leg Sproule, C.; Rich, P. B.; Guenther, B. D.; Pearlstein, R. D. Kikuchi, S.; Hasue, M.; Ischemic contracture in the 1978 Clinical PICO 8: Physical Exam insufficient data for Watanabe, M. lower limb Orthopaedics & Awake target condition; 1 CS Related Research Koskinen, E. V.; Nummi, Traumatic ischaemia causing 1967 Annales Chirurgiae PICO 8: Physical Exam insufficient data for J. the anterior tibial et Gynaecologiae Awake target condition compartment syndrome Fenniae Kumta, S. M.; Nehete, Challenges Posed by Delayed 2016 Hand Clinics PICO 8: Physical Exam review R.; Jain, L. Presentation of Mutilating Awake Hand Injuries

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Lunceford, E. M., Jr. The Peroneal Compartment 1965 Southern Medical PICO 8: Physical Exam case report Syndrome Journal Awake Lupu, C. M.; Davis, B. Tibial nailing causes 2014 Techniques in PICO 8: Physical Exam Insufficient data for compartment syndrome Orthopaedics Awake diagnostic compared with external comparison fixation in acute closed tibial fractures Mehrez, M. Complications of Fractures 1963 Journal of the PICO 8: Physical Exam review Egyptian Medical Awake Association Meskey, T.; Hardcastle, Are certain fractures at 2011 Journal of Trauma- PICO 8: Physical Exam insufficient data for J.; O'Toole, R. V. increased risk for Injury Infection & Awake target comparison compartment syndrome after Critical Care civilian ballistic injury? Nelson, K. J. Complicated fractures of the 2004 Trauma PICO 8: Physical Exam review forearm Awake Prasarn, M. L.; Ouellette, Acute compartment syndrome 2011 Journal of the PICO 8: Physical Exam review E. A. of the upper extremity American Academy Awake of Orthopaedic Surgeons Ragland, R., 3rd; Forearm compartment 2005 Journal of Hand PICO 8: Physical Exam retrospective case Moukoko, D.; Ezaki, M.; syndrome in the newborn: Surgery - American Awake series Carter, P. R.; Mills, J. report of 24 cases Volume Rorabeck, C. H.; The pathophysiology of the 1975 Clinical PICO 8: Physical Exam review Macnab, I. anterior tibial compartmental Orthopaedics & Awake syndrome Related Research Sagban, T. A.; Duran, Outcomes after complication 2015 Italian Journal of PICO 8: Physical Exam insufficient data for M.; Schelzig, H.; of femoral cannulation for Vascular and Awake target comparison Lichtenberg, A.; Albert, cardiac support Endovascular A.; Antakyali, F.; Surgery Dalyanoglu, H. Sanderson, R. A.; Foley, Histological response on 1975 Clinical PICO 8: Physical Exam review R. K.; McIvor, G. W.; skeletal muscle to ischemia Orthopaedics & Awake Kirkaldy-Willis, W. H. Related Research

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Schaffzin, J. K.; Prichard, A collaborative system to 2013 Pediatrics PICO 8: Physical Exam pico not answered; H.; Bisig, J.; Gainor, P.; improve compartment Awake education/awareness Wolfe, K.; Solan, L. G.; syndrome recognition intervention Webster, L.; McCarthy, J. J. Smith, R. M.; Dyer, G. S. Disaster triage after the 2012 Injury PICO 8: Physical Exam insufficient data for M.; Antonangeli, K.; Haitian earthquake Awake target comparison Arredondo, N.; Bedlion, H.; Dalal, A.; Deveny, G. M.; Joseph, G.; Lauria, D.; Lockhart, S. H.; Lucien, S.; Marsh, S.; Rogers, S. O.; Salzarulo, H.; Shah, S.; Toussaint, R. J.; Wagoner, J. Stark, E.; Stucken, C.; Compartment syndrome in 2009 Journal of PICO 8: Physical Exam insufficient data for Trainer, G.; Tornetta, P., Schatzker type VI plateau Orthopaedic Trauma Awake target condition 3rd fractures and medial condylar fracture-dislocations treated with temporary external fixation Su, H. Y.; Li, Y. H.; Tang, Can surgery in patient with 2016 Hong Kong Journal PICO 8: Physical Exam Insufficient data for C. N.; Su, C. I.; Tsai, M. Protobothrops of Emergency Awake target condition; 5 CS J. mucrosquamatus Medicine envenomation be predicted in emergency department? Tanaka, D.; Hirose, H.; The Impact of Vascular 2016 Annals of Thoracic PICO 8: Physical Exam Insufficient data for Cavarocchi, N.; Complications on Survival of Surgery Awake diagnostic Entwistle, J. W. C. Patients on Venoarterial comparison Extracorporeal Membrane Oxygenation Tekin, R.; Sula, B.; Cakir, Comparison of snakebite 2015 European Review for PICO 8: Physical Exam insufficient data for G.; Aktar, F.; Deveci, Ã?; cases in children and adults Medical and Awake target condition; 5 Yolbas, I.; Ã?elen, M. K.; Pharmacological fasciotomies Bekcibasi, M.; Palanci, Sciences Y.; Dogan, E.

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Ziran, B. H.; Becher, S. Radiographic predictors of 2013 Journal of PICO 8: Physical Exam pico not answered; J. compartment syndrome in Orthopaedic Trauma Awake CS outcome tibial plateau fractures Zuchelli, D.; Divaris, N.; Extremity compartment 2017 Journal of Surgical PICO 8: Physical Exam insufficient data for McCormack, J. E.; syndrome following blunt Research Awake target comparison; Huang, E. C.; trauma: a level I trauma CS outcome Chaudhary, N. D.; center's 5-year experience Vosswinkel, J. A.; Jawa, R. S. Cascio, B. M.; Pateder, Compartment syndrome: time 2005 Journal of Surgical PICO 8: Physical Exam insufficient data for D. B.; Wilckens, J. H.; from diagnosis to fasciotomy Orthopaedic Awake; PICO 10: target comparison Frassica, F. J. Advances Fasciotomy Methods Mao, Y. C.; Liu, P. Y.; Naja atra snakebite in Taiwan 2017 Clinical Toxicology: PICO 8: Physical Exam insufficient data for Chiang, L. C.; Lai, C. S.; The Official Journal Awake; PICO 10: target comparison Lai, K. L.; Ho, C. H.; of the American Fasciotomy Methods Wang, T. H.; Yang, C. C. Academy of Clinical Toxicology & European Association of Poisons Centres & Clinical Toxicologists Martinez, S. F.; Thigh Compartment 1993 Physician & PICO 8: Physical Exam Review; case report Steingard, M. A.; Syndrome Sportsmedicine Awake; PICO 10: Steingard, P. M. Fasciotomy Methods Chang, Y. H.; Tu, Y. K.; Tibial plateau fracture with 2000 Chang Gung PICO 8: Physical Exam insufficient data for Yeh, W. L.; Hsu, R. W. compartment syndrome: a Medical Journal Awake; PICO 10: target comparison complication of higher Fasciotomy Methods; incidence in Taiwan PICO 13: Associative Fracture; PICO 6: Pressure Methods Kim, J. Y.; Schierle, C. A prognostic model for the 2009 Annals of Plastic PICO 8: Physical Exam Insufficient data for F.; Subramanian, V. S.; risk of development of upper Surgery Awake; PICO 12: Wound target comparison; Birman, M. V.; Kloeters, extremity compartment Management risk of CS O.; Forte, A. J.; Basu, C. syndrome in the setting of brachial artery injury

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion B.; Wall, M. J., Jr.; Epstein, M.

Gerdin, M.; Wladis, A.; Surgical management of 2012 Journal of Trauma PICO 8: Physical Exam systematic review Von Schreeb, J. closed crush injury-induced and Acute Care Awake; PICO 13: compartment syndrome after Surgery Associative Fracture earthquakes in resource- scarce settings Kurt, N.; KÃ¼Ã§Ã¼k, H. Crush injury in two 2003 European Journal of PICO 8: Physical Exam insufficient data for F.; Demirhan, R.; Altaca, earthquake disasters within a Trauma Awake; PICO 13: target comparison G. 3-month period Associative Fracture Mithofer, K.; Lhowe, D. Clinical spectrum of acute 2004 Clinical PICO 8: Physical Exam insufficient data for W.; Vrahas, M. S.; compartment syndrome of the Orthopaedics & Awake; PICO 13: target comparison; Altman, D. T.; Altman, G. thigh and its relation to Related Research Associative Fracture <10 per ACS group T. associated injuries Gelberman, R. H.; Compartment syndromes of 1981 Clinical PICO 8: Physical Exam insufficient data for Garfin, S. R.; the forearm: diagnosis and Orthopaedics & Awake; PICO 6: Pressure target comparison Hergenroeder, P. T.; treatment Related Research Methods Mubarak, S. J.; Menon, J. Phillips, J. H.; Vibratory sensory testing in 1987 Plastic and PICO 8: Physical Exam <20 patients; n11 Mackinnon, S. E.; Beatty, acute compartment Reconstructive Awake; PICO 6: Pressure S. E. syndromes: A clinical and Surgery Methods experimental study Aars, H. The anterior tibial syndrome 1961 Journal of the Oslo PICO 10: Fasciotomy case reports City Hospitals Methods Abene, A. J.; Esterhai, J. Soft tissue management of 1997 Techniques in PICO 10: Fasciotomy review L., Jr. compartment syndrome Orthopaedics Methods fasciotomy and Gustilo and Anderson Type IIIb open fracture wounds

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Andro, C.; Dubrana, F.; Painful medial knee 2011 Orthopaedics & PICO 10: Fasciotomy pico not answered; no Marcillaud, G.; compartment syndrome in traumatology, Methods CS Rouvillain, J. L.; over-45 year-olds: I--medical surgery & research Gunepin, F. X.; or surgical management: a Dewerpe, P.; Guilbert, series of 174 patients S.; Wessely, L.; Buisson, P.; Chicault, P.; Nguyen- Khanh, J. P.; Brune, T.; Dhenain, M.; Maugars, Y. Anonymous, Erratum for "acute pediatric 2015 Orthopedics PICO 10: Fasciotomy not a clinical study leg compartment syndrome in Methods chronic myeloid leukemia".[Erratum for Orthopedics. 2014 Nov;37(11):e1036-9 Note: Trunzter, Jeremy [corrected to Truntzer, Jeremy]; PMID: 25361367] Asgari, M. M.; Spinelli, H. The vessel loop shoelace 2000 Annals of Plastic PICO 10: Fasciotomy insufficient data for M. technique for closure of Surgery Methods target comparison fasciotomy wounds Auld, T. S.; Hwang, J. S.; The correlation between the 2017 Journal of PICO 10: Fasciotomy insufficient data for Stekas, N.; Gibson, P. OTA/AO classification system Orthopaedic Trauma Methods target comparison D.; Sirkin, M. S.; Reilly, and compartment syndrome M. C.; Adams, M. R. in both bone forearm fractures Bernhard, W. N.; Critical care management of 1993 International PICO 10: Fasciotomy incidence and review Tarantino, D. P.; Gerold, the trauma patient Anesthesiology Methods K. B. Clinics Blick, S. S.; Brumback, Compartment syndrome in 1986 Journal of Bone & PICO 10: Fasciotomy insufficient data; ACS R. J.; Poka, A.; Burgess, open tibial fractures Joint Surgery - Methods as outcome A. R.; Ebraheim, N. A. American Volume Bradley, E. L., 3rd The anterior tibial 1973 Surgery, Gynecology PICO 10: Fasciotomy review compartment syndrome & Obstetrics Methods

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Branco, B. C.; Inaba, K.; Incidence and predictors for 2011 Injury PICO 10: Fasciotomy insufficient data for Barmparas, G.; the need for fasciotomy after Methods target condition Schnuriger, B.; extremity trauma: a 10-year Lustenberger, T.; review in a mature level I Talving, P.; Lam, L.; trauma centre Demetriades, D. Broom, A.; Schur, M. D.; Compartment syndrome in 2016 Journal of Childrens PICO 10: Fasciotomy <20 patients; n15 Arkader, A.; Flynn, J.; infants and toddlers Orthopaedics Methods Gornitzky, A.; Choi, P. D. Brown, C. M.; Vitale, G. Compartment syndromes and 1987 Journal of the PICO 10: Fasciotomy review C.; Evers, B. M.; the use of fasciotomy Kentucky Medical Methods Richardson, J. D. Association Brown, R. L.; The adequacy of limb 1994 Journal of Trauma- PICO 10: Fasciotomy insufficient data for Greenhalgh, D. G.; escharotomies-fasciotomies Injury Infection & Methods target condition Kagan, R. J.; Warden, G. after referral to a major burn Critical Care D. center Burg, M. E. Compartment syndrome 1983 Critical Care PICO 10: Fasciotomy review Quarterly Methods Chenevey, B.; Sexton- Lower limb ischemia: an 1985 DCCN - Dimensions PICO 10: Fasciotomy Irrelevant topic; Stone, K. iatrogenic complication of of Critical Care Methods ischemia IABP Nursing Christoffersen, J. K.; Well Leg Compartment 2017 World Journal of PICO 10: Fasciotomy insufficient data for Hove, L. D.; Mikkelsen, Syndrome After Abdominal Surgery Methods target comparison K. L.; Krogsgaard, M. R. Surgery Cohen, M. S.; Garfin, S. Acute compartment 1991 Journal of Bone & PICO 10: Fasciotomy <20 patients; n8 R.; Hargens, A. R.; syndrome. Effect of Joint Surgery - Methods Mubarak, S. J. dermotomy on fascial British Volume decompression in the leg Cui, S.; Bauer, J. M.; Mir, Bilateral tibial shaft fractures: 2017 Current Orthopaedic PICO 10: Fasciotomy insufficient data for H.; Cannada, L. K. A multicenter analysis Practice Methods target condition; CS outcome Darracq, M. A.; Cantrell, A chance to cut is not always 2015 Toxicon PICO 10: Fasciotomy Insufficient data for F. L.; Klauk, B.; a chance to cure- fasciotomy Methods target condition Thornton, S. L. in the treatment of rattlesnake envenomation: A

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion retrospective poison center study

Dente, C. J.; Feliciano, A review of upper extremity 2004 American Surgeon PICO 10: Fasciotomy insufficient data for D. V.; Rozycki, G. S.; fasciotomies in a level I Methods target comparison; no Cava, R. A.; Ingram, W. trauma center comparison grps L.; Salomone, J. P.; Nicholas, J. M.; Kanakasundaram, D.; Ansley, J. P. Diwan, A. Lower leg fasciotomy: 2- 2012 Techniques in PICO 10: Fasciotomy review Incision technique Orthopaedics Methods Dombrowski, R. M. Compartment syndromes 1998 Trauma PICO 10: Fasciotomy review Methods Doukas, W. C.; Hayda, The Military Extremity Trauma 2013 Journal of Bone and PICO 10: Fasciotomy insufficient data for R. A.; Frisch, H. M.; Amputation/Limb Salvage Joint Surgery - Methods target condition Andersen, R. C.; (METALS) study: Outcomes Series A Mazurek, M. T.; Ficke, J. of amputation versus limb R.; Keeling, J. J.; salvage following major lower- Pasquina, P. F.; Wain, H. extremity Trauma J.; Carlini, A. R.; MacKenzie, E. J. du Plessis, H. J.; Marais, Compartment syndrome and 1983 South African PICO 10: Fasciotomy Insufficient data for T. J.; van Wyk, F. A.; fasciotomy Journal of Surgery Methods target condition; 1 CS Mieny, C. J. Dulhunty, J. M.; Boots, Increased fluid resuscitation 2008 Burns PICO 10: Fasciotomy insufficient data for R. J.; Rudd, M. J.; can lead to adverse outcomes Methods target comparison Muller, M. J.; Lipman, J. in major-burn injured patients, but low mortality is achievable Eaton, R. G. Hand problems in children. A 1967 Pediatric Clinics of PICO 10: Fasciotomy review timetable for management North America Methods Ebraheim, N. A.; A Single-Incision Fasciotomy 2016 Journal of PICO 10: Fasciotomy no comparison group Siddiqui, S.; Raberding, for Compartment Syndrome of Orthopaedic Trauma Methods C. the Lower Leg

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Farahvash, M. R.; Surgical approach to 2009 International Journal PICO 10: Fasciotomy pico not answered; Yegane, R. A.; hydrocarbon injection in upper Of Surgery Methods CS outcome Bashashati, M.; Ahmadi, extremities: case series M.; Tabrizi, N. Farber, A.; Tan, T. W.; Early fasciotomy in patients 2012 Injury PICO 10: Fasciotomy insufficient data for Hamburg, N. M.; Kalish, with extremity vascular injury Methods target condition J. A.; Joglar, F.; is associated with decreased Onigman, T.; Rybin, D.; risk of adverse limb Doros, G.; Eberhardt, R. outcomes: a review of the T. National Trauma Data Bank Feliciano, D. V.; Cruse, Fasciotomy after trauma to 1988 American Journal of PICO 10: Fasciotomy insufficient data for P. A.; Spjut-Patrinely, V.; the extremities Surgery Methods target comparison Burch, J. M.; Mattox, K. L. Field, C. K.; Senkowsky, Fasciotomy in vascular 1994 American Surgeon PICO 10: Fasciotomy insufficient data for J.; Hollier, L. H.; trauma: is it too much, too Methods target condition Kvamme, P.; Saroyan, often? R. M.; Rice, J. C.; Rush, D. S.; Kerstein, M. D. Fitzgerald, A. M.; Long-term sequelae of 2000 British Journal of PICO 10: Fasciotomy Insufficient data for Gaston, P.; Wilson, Y.; fasciotomy wounds Plastic Surgery Methods target comparison Quaba, A.; McQueen, M. M. Fowler, P. J.; Willis, R. B. Vascular compartment 1975 Canadian Journal of PICO 10: Fasciotomy case reports syndromes Surgery Methods Frangides, C. Y.; Snake venom poisoning in 2006 European Journal of PICO 10: Fasciotomy insufficient data for Koulouras, V.; Kouni, S. Greece. Experiences with 147 Internal Medicine Methods target condition; 2 CS N.; Tzortzatos, G. V.; cases Nikolaou, A.; Pneumaticos, J.; Pierrakeas, C.; Niarchos, C.; Kounis, N. G.; Koutsojannis, C. M. Gee, W. Compartment compression 1988 Emergency Care PICO 10: Fasciotomy review syndrome Quarterly Methods

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion George, S. M.; Hsu, J. Documentation of acute 2015 Journal of Surgical PICO 10: Fasciotomy Insufficient data for R.; Kragh, J.; Stinner, D. compartment syndrome Orthopaedic Methods target comparison J. during medical evacuation Advances Giannoudis, P. V.; Long-term quality of life in 2009 Injury PICO 10: Fasciotomy insufficient data for Harwood, P. J.; Kontakis, trauma patients following the Methods target comparison G.; Allami, M.; full spectrum of tibial injury Macdonald, D.; Kay, S. (fasciotomy, closed fracture, P.; Kind, P. grade IIIB/IIIC open fracture and amputation) Girard-Martel, C.; Acute Bilateral Compartment 2015 Clinical PICO 10: Fasciotomy case report Gagnon, M. Syndrome Secondary to Schizophrenia & Methods Polydipsia-Induced Severe Related Psychoses Hyponatremia Glancy, G. L. Compartment syndromes 1976 ONA Journal PICO 10: Fasciotomy review Methods Godfrey, B. W.; Martin, Patients with multiple 2017 Injury PICO 10: Fasciotomy Insufficient data for A.; Chestovich, P. J.; traumatic amputations: An Methods target conditions; 4 Lee, G. H.; Ingalls, N. K.; analysis of operation enduring CS Saldanha, V. freedom joint theatre trauma registry data Gresh, M. Compartment syndrome in 2017 Pediatrics in Review PICO 10: Fasciotomy review the pediatric patient Methods Hak, D. J.; Lee, M.; Influence of prior fasciotomy 2010 Journal of Trauma- PICO 10: Fasciotomy <10 pts per Gotham, D. R. on infection after open Injury Infection & Methods comparison group reduction and internal fixation Critical Care of tibial plateau fractures Harrah, J.; Gates, R.; A simpler, less expensive 2000 American Journal of PICO 10: Fasciotomy review; 6 pts Carl, J.; Harrah, J. D. technique for delayed primary Surgery Methods closure of fasciotomies Hughes, C. W.; Anterior tibial compartment 1961 Military Medicine PICO 10: Fasciotomy case reports Lineberger, E. C.; syndrome: a plea for early Methods Bowers, W. F. surgical treatment Iyem, H.; Eren, M. N. Should embolectomy be 2009 Vascular Health & PICO 10: Fasciotomy pico not answered; performed in late acute lower Risk Management Methods CS outcome extremity arterial occlusions?

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Janzing, H. M. Epidemiology, Etiology, 2007 European Journal of PICO 10: Fasciotomy systematic review Pathophysiology and Trauma & Methods Diagnosis of the Acute Emergency Surgery Compartment Syndrome of the Extremity Jauregui, J. J.; Yarmis, Fasciotomy closure 2017 Journal of PICO 10: Fasciotomy systematic review S. J.; Tsai, J.; Onuoha, techniques Orthopaedic Surgery Methods K. O.; Illical, E.; Paulino, C. B. Jensen, S. L.; Compartment syndrome and 1997 European Journal of PICO 10: Fasciotomy not best available Sandermann, J. fasciotomy in vascular Vascular & Methods evidence surgery. A review of 57 cases Endovascular Surgery Johnson, S. B.; Weaver, Clinical results of 1992 American Journal of PICO 10: Fasciotomy no comparison group F. A.; Yellin, A. E.; Kelly, decompressive dermotomy- Surgery Methods R.; Bauer, M. fasciotomy Kalb, R. L. Preventing the sequelae of 1999 Hospital practice PICO 10: Fasciotomy review compartment syndrome (1995) Hospital Methods practice Kalish, J.; Nguyen, T.; Associated venous injury 2012 International Journal PICO 10: Fasciotomy pico not answered; Hamburg, N.; Eberhardt, significantly complicates of Angiology Methods CS outcome R.; Rybin, D.; Doros, G.; presentation, management, Farber, A. and outcomes of axillosubclavian arterial trauma Kashuk, J. L.; Moore, E. Lower extremity compartment 2009 Patient Safety in PICO 10: Fasciotomy no comparison group E.; Pinski, S.; Johnson, syndrome in the acute care Surgery [Electronic Methods J. L.; Moore, J. B.; surgery paradigm: safety Resource] Morgan, S.; Cothren, C. lessons learned C.; Smith, W. Khalil, I. Pitfalls in the management of 1986 Problems in General PICO 10: Fasciotomy review compartmental syndromes Surgery Methods Khan, M. I.; Nadeem, I. Revascularization Of Late- 2016 Journal of Ayub PICO 10: Fasciotomy insufficient data for A. Presenting Acute Limb Medical College, Methods target condition and Ischaemia And Limb Salvage Abbottabad: JAMC outcomes

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Kistler, J. M.; Ilyas, A. Forearm Compartment 2018 Hand Clinics PICO 10: Fasciotomy review M.; Thoder, J. J. Syndrome: Evaluation and Methods Management Kochhar, V. L.; Saxena, Anterior tibial compartment 1986 Journal of the Indian PICO 10: Fasciotomy case report A. K. syndrome Medical Association Methods Kragh, J. F., Jr.; Dubick, U.S. Military Experience From 2016 Military Medicine PICO 10: Fasciotomy insufficient data for M. A.; Aden, J. K., 3rd; 2001 to 2010 With Extremity Methods target condition McKeague, A. L.; Fasciotomy in War Surgery Rasmussen, T. E.; Baer, D. G.; Blackbourne, L. H. Kragh, J. F., Jr.; San Compartment syndrome 2013 The Journal of PICO 10: Fasciotomy not best available Antonio, J.; Simmons, J. performance improvement Trauma and Acute Methods evidence W.; Mace, J. E.; Stinner, project is associated with Care Surgery D. J.; White, C. E.; Fang, increased combat casualty R.; Aden, J. K.; Hsu, J. survival R.; Eastridge, B. J.; Jenkins, D. H.; Ritchie, J. D.; Hardin, M. O.; Ritenour, A. E.; Wade, C. E.; Blackbourne, L. H. Kragh, J. F., Jr.; Wade, Fasciotomy rates in 2011 Journal of PICO 10: Fasciotomy incidence rates for C. E.; Baer, D. G.; operations enduring freedom Orthopaedic Trauma Methods fasciotomy Jones, J. A.; Walters, T. and iraqi freedom: association J.; Hsu, J. R.; Wenke, J. with injury severity and C.; Blackbourne, L. H.; tourniquet use Holcomb, J. B. Kricun, M. E. Wrist arthrography 1984 Clinical PICO 10: Fasciotomy review Orthopaedics & Methods Related Research Kunkel, M. G.; Lynn, R. The anterior tibial 1958 Canadian Journal of PICO 10: Fasciotomy review B. compartment syndrome Surgery Methods Lagerstrom, C. F.; Reed, Early fasciotomy for acute 1989 American Journal of PICO 10: Fasciotomy Insufficient data for R. L., 2nd; Rowlands, B. clinically evident Surgery Methods target comparison J.; Fischer, R. P. posttraumatic compartment syndrome

Authors Article Title Year Expanded Recommendations Reason for Periodical Exclusion Title Lintz, F.; Colombier, J. Management of long-term 2009 Foot & PICO 10: Fasciotomy <20 patients; n10 A.; Letenneur, J.; Gouin, sequelae of compartment Ankle Methods F. syndrome involving the foot Internation and ankle al Lisle, D. K.; Tucker, J. B. Exertional compartment 2004 Physician & PICO 10: Fasciotomy case study syndrome in an equestrian Sportsmedicine Methods does inadequate staffing compromise healthcare? Low, E. E.; Inkellis, E.; Complications and revision 2017 Injury PICO 10: Fasciotomy insufficient data for Morshed, S. amputation following trauma- Methods target condition related lower limb loss MÃ¤rdian, S.; Schaser, Lower limb salvage: Indication 2014 Acta Chirurgiae PICO 10: Fasciotomy systematic review K. D.; Wichlas, F.; and decision making for Orthopaedicae et Methods Jakobs, C.; Kraphol, B.; replantation, revascularisation Traumatologiae Schwabe, P. and amputation Cechoslovaca Maheshwari, R.; Single-incision fasciotomy for 2008 Journal of PICO 10: Fasciotomy insufficient data for Taitsman, L. A.; Barei, D. compartmental syndrome of Orthopaedic Methods target comparison P. the leg in patients with Trauma diaphyseal tibial fractures Malik, A. A.; Khan, W. S.; Acute compartment 2009 Journal of PICO 10: Fasciotomy review Chaudhry, A.; Ihsan, M.; syndrome--a life and limb Perioperative Methods Cullen, N. P. threatening surgical Practice emergency Mann, R.; Gibran, N.; Is immediate decompression 1996 Journal of PICO 10: Fasciotomy insufficient data for Engrav, L.; Heimbach, D. of high voltage electrical Trauma- Injury Methods target comparison injuries to the upper extremity Infection & always necessary? Critical Care Marchesi, M.; Marchesi, A sneaky surgical emergency: 2014 Injury PICO 10: Fasciotomy insufficient data for A.; Calori, G. M.; Cireni, Acute compartment Methods target outcomes; legal L. V.; Sileo, G.; syndrome. Retrospective assessment Merzagora, I.; Zoia, R.; analysis of 66 closed claims, Vaienti, L.; Morini, O. medico-legal pitfalls and damages evaluation Masini, B. D.; Racusin, Acute compartment syndrome 2013 Journal of PICO 10: Fasciotomy insufficient data for A. W.; Wenke, J. C.; of the thigh in combat Surgical Methods target comparison casualties Orthopaedic 94 Advances

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Gerlinger, T. L.; Hsu, J. R.

Matsen, F. A., 3rd Compartmental syndromes 1980 Hospital Practice PICO 10: Fasciotomy review Methods McKeag, D. B.; Dolan, C. Overuse syndromes of the 1989 Physician and PICO 10: Fasciotomy review lower extremity Sportsmedicine Methods McKenney, M. G.; Nir, I.; A simple device for closure of 1996 American Journal of PICO 10: Fasciotomy <20 patients; n13 Fee, T.; Martin, L.; Lentz, fasciotomy wounds Surgery Methods K. Modrall, J. G.; Sadjadi, Deep vein harvest: predicting 2004 Journal of Vascular PICO 10: Fasciotomy insufficient data; 0 CS J.; Ali, A. T.; Anthony, T.; need for fasciotomy Surgery Methods pts Welborn, M. B., 3rd; Valentine, R. J.; Hynan, L. S.; Clagett, G. P. Montgomery, W. S. The anterior tibial syndrome 1960 North Carolina PICO 10: Fasciotomy case report Medical Journal Methods Mravic, P. J.; Massey, D. Compartment syndrome 1992 Journal of Vascular PICO 10: Fasciotomy review M. Nursing Methods Mubarak, S. J.; Owen, C. Double-incision fasciotomy of 1977 Journal of Bone & PICO 10: Fasciotomy case series; cadavers A. the leg for decompression in Joint Surgery - Methods included compartment syndromes American Volume Naidu, S. I.; Bergquist, V. Compartment syndromes in 1977 American Surgeon PICO 10: Fasciotomy case reports F. the leg: a surgical emergency Methods Palm, K.; Apodaca, A.; Evaluation of military trauma 2012 The Journal of PICO 10: Fasciotomy insufficient data for Spencer, D.; Costanzo, system practices related to Trauma and Acute Methods target comparison G.; Bailey, J.; Fortuna, complications after injury Care Surgery G.; Blackbourne, L. H.; Spott, M. A.; Eastridge, B. J. Papalambros, E. L.; Prophylactic fasciotomy of the 1989 International PICO 10: Fasciotomy insufficient target Panayiotopoulos, Y. P.; legs following acute arterial Angiology Methods outcomes Bastounis, E.; Zavos, G.; occlusion procedures Balas, P.

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Patman, R. D. Compartmental syndromes in 1975 Clinical PICO 10: Fasciotomy review peripheral vascular surgery Orthopaedics & Methods Related Research Paton, D. F. The anterior/tibial/syndrome 1981 Practitioner PICO 10: Fasciotomy review Methods Pattinson, J. P.; Kong, V. Defining the need for surgical 2017 South African PICO 10: Fasciotomy insufficient data for Y.; Bruce, J. L.; intervention following a Medical Journal Methods target condition; 14 Oosthuizen, G. V.; snakebite still relies heavily CS Bekker, W.; Laing, G. L.; on clinical assessment: The Wood, D.; Brysiewicz, P.; experience in Clarke, D. L. pietermaritzburg, South Africa Pinkowski, J. L.; Weiner, Complications in proximal 1995 Journal of Pediatric PICO 10: Fasciotomy Insufficient data for D. S. tibial osteotomies in children Orthopaedics Methods target condition; no with presentation of technique CS Pourzand, A.; Fakhri, B. Management of high-risk 2010 Vascular Health and PICO 10: Fasciotomy insufficient data for A.; Azhough, R.; popliteal vascular blunt Risk Management Methods target condition Hassanzadeh, M. A.; trauma: Clinical experience Hashemzadeh, S.; with 62 cases Bayat, A. M. Proehl, J. A. Compartment 1988 Journal of PICO 10: Fasciotomy review syndrome.[Erratum appears Emergency Nursing Methods in J Emerg Nurs 1989 Jan- Feb;15(1):7] Proehl, J. A. Compartment syndrome 1988 Journal of PICO 10: Fasciotomy review emergency nursing: Methods JEN : official publication of the Emergency Department Nurses Association

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Rajan, D. K.; Patel, N. Quality Improvement 2009 Journal of Vascular PICO 10: Fasciotomy systematic review H.; Valji, K.; Cardella, J. Guidelines for Percutaneous and Interventional Methods F.; Brown, D. B.; Management of Acute Limb Radiology Brountzos, E. N.; Clark, Ischemia T. W. I.; Grassi, C. J.; Meranze, S. G.; Miller, D. L.; Neithamer, C. D.; Rholl, K.; Roberts, A.; Schwartzberg, M. S.; Swan, T. T.; Thorpe, P. E.; Towbin, R. B.; Sacks, D. Rammelt, S.; Zwipp, H. Calcaneus fractures 2006 Trauma PICO 10: Fasciotomy review Methods Ritenour, A. E.; Dorlac, Complications after 2008 Journal of Trauma- PICO 10: Fasciotomy not best available W. C.; Fang, R.; Woods, fasciotomy revision and Injury Infection & Methods evidence T.; Jenkins, D. H.; delayed compartment release Critical Care Flaherty, S. F.; Wade, C. in combat patients E.; Holcomb, J. B. Roberts, A. J.; Outcomes of surgery for 2015 Journal of the Royal PICO 10: Fasciotomy chronic Krishnasamy, P.; chronic exertional Army Medical Corps Methods Quayle, J. M.; Houghton, compartment syndrome in a J. M. military population Rodriguez-Merchan, E. Musculo-skeletal 2016 Blood Reviews PICO 10: Fasciotomy review C. manifestations of haemophilia Methods Rollins, D. L.; Bernhard, Fasciotomy: an appraisal of 1981 Archives of Surgery PICO 10: Fasciotomy confounded patients V. M.; Towne, J. B. controversial issues Methods and treatments Rorabeck, C. H.; Anterior tibial-compartment 1976 Journal of Bone & PICO 10: Fasciotomy insufficient data for Macnab, L. syndrome complicating Joint Surgery - Methods target condition; 6 CS fractures of the shaft of the American Volume pts tibia

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Rosales-Varo, A. P.; Coronal patellar osteotomy of 2016 Revista Espanola de PICO 10: Fasciotomy Insufficient data for Roda-Murillo, O.; the external facet combined Cirugia Ortopedica y Methods target comparison; Prados-Olleta, N.; with the release of the lateral Traumatologia not acute Garcia-Espona, M. A. retinaculum improves the clinical outcomes of isolated lateral release in lateral knee compartment syndrome Rubinstein, A. J.; Hand Compartment 2018 Hand Clinics PICO 10: Fasciotomy review Ahmed, I. H.; Vosbikian, Syndrome Methods M. M. Rush, D. S.; Frame, S. Does open fasciotomy 1989 Journal of Vascular PICO 10: Fasciotomy Insufficient data for B.; Bell, R. M.; Berg, E. contribute to morbidity and Surgery Methods target outcomes E.; Kerstein, M. D.; mortality after acute lower Haynes, J. L. extremity ischemia and revascularization? Sandzen Jr, S. C. Crush injuries of the upper 1990 American Family PICO 10: Fasciotomy review extremity Physician Methods Schmidt, C. A.; Rancic, Hypothermic, initially oxygen- 2015 Annals of Vascular PICO 10: Fasciotomy insufficient data for Z.; Lachat, M. L.; Mayer, free, controlled limb Surgery Methods target comparison D. O.; Veith, F. J.; reperfusion for acute limb Wilhelm, M. J. ischemia Schonholtz, G. J. Traumatic anterior tibial artery 1972 Southern Medical PICO 10: Fasciotomy review syndrome Journal Methods Shelton, W. R.; Canale, Fractures of the tibia through 1979 Journal of Bone & PICO 10: Fasciotomy insufficient data; 1 CS S. T. the proximal tibial epiphyseal Joint Surgery - Methods outcome cartilage American Volume Sher, M. H. Principles in the management 1975 Annals of Surgery PICO 10: Fasciotomy <20 patients; n10 of arterial injuries associated Methods with fracture/dislocations Sheridan, G. W.; Matsen, Fasciotomy in the treatment 1976 Journal of Bone & PICO 10: Fasciotomy not best available F. A., 3rd of the acute compartment Joint Surgery - Methods evidence syndrome American Volume Singer, A. Surgical pros and cons. 1979 Surgery, Gynecology PICO 10: Fasciotomy review Compartmental syndromes & Obstetrics Methods

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Singh, A.; Ali, S.; Evaluation of acute 2015 Internet Journal of PICO 10: Fasciotomy not best available Srivastava, R. N. compartment syndrome of Medical Update Methods evidence extremities in emergency room: A case series of 32 children Skaggs, D. L.; Roy, A. Quality of evaluation and 2002 Journal of Pediatric PICO 10: Fasciotomy insufficient data for K.; Vitale, M. G.; Pfiefer, management of children Orthopedics Methods target condition; 1 CS C.; Baird, G.; Femino, D.; requiring timely orthopaedic Kay, R. M. surgery before admission to a tertiary pediatric facility Subotnick, S. I. Compartment syndromes in 1975 Journal of the PICO 10: Fasciotomy review the lower extremities American Podiatry Methods Association Trainor, T. Knee dislocation 2000 Trauma PICO 10: Fasciotomy review Methods Vaillancourt, C.; Shrier, Quantifying delays in the 2001 CJEM Canadian PICO 10: Fasciotomy Insufficient data for I.; Falk, M.; Rossignol, recognition and management Journal of Methods target outcomes M.; Vernec, A.; Somogyi, of acute compartment Emergency Medical D. syndrome Care Van Den Brand, J. G. H.; Acute Compartment 2004 European Journal of PICO 10: Fasciotomy not best available Sosef, N. L.; Syndrome after Lower Leg Trauma Methods evidence Verleisdonk, E. J. M. M.; Fracture: Long-Term Results Van Der Werken, C. of Prophylactic and Therapeutic Fasciotomy Velmahos, G. C.; Complications and nonclosure 1997 World Journal of PICO 10: Fasciotomy not best available Theodorou, D.; rates of fasciotomy for trauma Surgery Methods evidence Demetriades, D.; Chan, and related risk factors L.; Berne, T. V.; Asensio, J.; Cornwell, Iii E. E.; Beizberg, H.; Stewart, B. M. Verwiebe, E. G.; Kanlic, Thigh compartment 2009 Bosnian Journal of PICO 10: Fasciotomy <20 patients; n9 E. M.; Saller, J.; syndrome, presentation and Basic Medical Methods Abdelgawad, A. complications Sciences

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Vitale, G. C.; Fasciotomy for severe, blunt 1988 Surgery, Gynecology PICO 10: Fasciotomy insufficient data for Richardson, J. D.; and penetrating trauma of the & Obstetrics Methods target comparison George, S. M., Jr.; Miller, extremity F. B. Walker, M.; Gaston, S. The effectiveness of different 2011 JBI Library of PICO 10: Fasciotomy systematic review fasciotomy wound Systematic Reviewis Methods management treatment options following acute compartment syndrome: A systematic review protocol Warner, M. E.; LaMaster, Compartment syndrome in 2001 Anesthesiology PICO 10: Fasciotomy prevalence study L. M.; Thoeming, A. K.; surgical patients Methods Marienau, M. E.; Warner, M. A. Weaver, M. J.; Owen, T. Delayed Primary Closure of 2015 Journal of PICO 10: Fasciotomy insufficient data for M.; Morgan, J. H.; Harris, Fasciotomy Incisions in the Orthopaedic Trauma Methods target outcomes M. B. Lower Leg: Do We Need to Change Our Strategy? Webber, J. Management of upper 1988 Emergency Care PICO 10: Fasciotomy review extremity injury: the first hour Quarterly Methods Weinik, M. M.; Falco, F. Acute and chronic 1992 Journal of Back & PICO 10: Fasciotomy review J. compartment syndromes of Musculoskeletal Methods the lower leg Rehabilitation Winkes, M. B.; van Fasciotomy for Deep 2016 The American PICO 10: Fasciotomy case series; no Zantvoort, A. P.; de Posterior Compartment journal of sports Methods comparison grp Bruijn, J. A.; Smeets, S. Syndrome in the Lower Leg: medicine J.; van der Cruijsen- A Prospective Study Raaijmakers, M.; Hoogeveen, A. R.; Scheltinga, M. R. Wood, D. I.; Bruce, A. S. Damage control orthopaedics 2015 Surgery (United PICO 10: Fasciotomy review W. Kingdom) Methods Yang, C. C.; Chang, D. Vacuum-assisted closure for 2006 Journal of Surgical PICO 10: Fasciotomy not best available S.; Webb, L. X. fasciotomy wounds following Orthopaedic Methods evidence Advances

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion compartment syndrome of the leg Yau, J.; Reach Jr, J. S. Pediatric foot fractures: 2009 Techniques in PICO 10: Fasciotomy review Metatarsal fractures Orthopaedics Methods Ziolkowski, N. I.; Zive, L.; Timing of Presentation of 2017 Plastic & PICO 10: Fasciotomy not best available Ho, E. S.; Zuker, R. M. Pediatric Compartment Reconstructive Methods evidence Syndrome and Its Surgery Microsurgical Implication: A Retrospective Review Zorrilla, P.; Marin, A.; Shoelace technique for 2005 Journal of Trauma- PICO 10: Fasciotomy insufficient data for Gomez, L. A.; Salido, J. gradual closure of fasciotomy Injury Infection & Methods target comparison; no A. wounds Critical Care comparison grps Lollo, L.; Grabinsky, A. Clinical and functional 2016 International Journal PICO 10: Fasciotomy Insufficient data for outcomes of acute lower of Critical Illness and Methods; PICO 11: Pre- target condition extremity compartment Injury Science op Adjunctive Therapy syndrome at a Major Trauma Hospital Flynn, J. M.; Bashyal, R. Acute traumatic compartment 2011 Journal of Bone & PICO 10: Fasciotomy not best available K.; Yeger-McKeever, M.; syndrome of the leg in Joint Surgery - Methods; PICO 11: Pre- evidence Garner, M. R.; Launay, children: diagnosis and American Volume op Adjunctive Therapy; F.; Sponseller, P. D. outcome PICO 3: Fasciotomy Missed ACS Bae, D. S.; Kadiyala, R. Acute compartment syndrome 2001 Journal of Pediatric PICO 10: Fasciotomy not best available K.; Waters, P. M. in children: contemporary Orthopedics Methods; PICO 12: evidence diagnosis, treatment, and Wound Management outcome Duckworth, A. D.; Acute compartment syndrome 2012 Journal of Bone & PICO 10: Fasciotomy not best available Mitchell, S. E.; Molyneux, of the forearm Joint Surgery - Methods; PICO 12: evidence S. G.; White, T. O.; American Volume Wound Management Court-Brown, C. M.; McQueen, M. M. Agarwal, N.; Shah, P. M.; Experience with 115 civilian 1982 Journal of Trauma- PICO 10: Fasciotomy insufficient data for Clauss, R. H.; Reynolds, venous injuries Injury Infection & Methods; PICO 13: target condition B. M.; Stahl, W. M. Critical Care Associative Fracture

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Besch, L.; Waldschmidt, The treatment of intra-articular 2010 Journal of Foot & PICO 10: Fasciotomy insufficient data for J. S.; Daniels- calcaneus fractures with Ankle Surgery Methods; PICO 13: target condition; no Wredenhagen, M.; severe soft tissue damage Associative Fracture CS values Varoga, D.; Mueller, M.; with a hinged external fixator Hilgert, R. E.; Mathiak, or internal stabilization: long- G.; Oestern, S.; term results Lippross, S.; Seekamp, A. Branco, B. C.; Linnebur, The predictive value of 2015 Injury PICO 10: Fasciotomy insufficient data for M.; Boutrous, M. L.; multidetector CTA on Methods; PICO 13: target comparison Leake, S. S.; Inaba, K.; outcomes in patients with Associative Fracture Charlton-Ouw, K. M.; below-the-knee vascular Azizzadeh, A.; Fortuna, injury G.; DuBose, J. J. Dellon, A. L. Clinical use of vibratory stimuli 1980 Plastic & PICO 10: Fasciotomy insufficient data for to evaluate peripheral nerve Reconstructive Methods; PICO 13: target comparison injury and compression Surgery Associative Fracture neuropathy Gall, W. E.; Burr, J. W.; Noninvasive evaluation and 1978 Surgical forum PICO 10: Fasciotomy animal study Wright, C. B. correlation of hemodynamics Methods; PICO 13: in "compartment syndrome" Associative Fracture Garrett, R. C.; Kerstein, Compartment syndrome in 1987 Southern Medical PICO 10: Fasciotomy case report M. D. the newborn Journal Methods; PICO 13: Associative Fracture Gonzalez, R. P.; Scott, Anatomic location of 2009 American Journal of PICO 10: Fasciotomy incidence rates W.; Wright, A.; Phelan, penetrating lower-extremity Surgery Methods; PICO 13: H. A.; Rodning, C. B. trauma predicts compartment Associative Fracture syndrome development Hope, M. J.; McQueen, Acute compartment syndrome 2004 Journal of PICO 10: Fasciotomy insufficient data for M. M. in the absence of fracture Orthopaedic Trauma Methods; PICO 13: target comparison Associative Fracture Partanen, T. A.; Outcome after injections of 2009 European Journal of PICO 10: Fasciotomy insufficient data for Vikatmaa, P.; Tukiainen, crushed tablets in intravenous Vascular & Methods; PICO 13: target condition E.; Lepantalo, M.; Vuola, drug abusers in the Helsinki Endovascular Associative Fracture J. University Central Hospital Surgery

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Stiles, Z. E.; Sparks, D. Acute Extremity Compartment 2017 American Surgeon PICO 10: Fasciotomy review A. Syndrome Secondary to Methods; PICO 13: Statin-Induced Myopathy Associative Fracture Streubel, P. N.; Gardner, Management of femur shaft 2011 Orthopedic Clinics of PICO 10: Fasciotomy review M. J.; Ricci, W. M. fractures in obese patients North America Methods; PICO 13: Associative Fracture Waterman, B. R.; Surgical treatment of chronic 2013 Journal of Bone & PICO 10: Fasciotomy chronic Laughlin, M.; Kilcoyne, exertional compartment Joint Surgery - Methods; PICO 13: K.; Cameron, K. L.; syndrome of the leg: failure American Volume Associative Fracture Owens, B. D. rates and postoperative disability in an active patient population Han, F.; Daruwalla, Z. J.; A prospective study of 2015 Journal of Foot & PICO 10: Fasciotomy <20 patients; n14 Shen, L.; Kumar, V. P. surgical outcomes and quality Ankle Surgery Methods; PICO 14: Foot of life in severe foot trauma ACS and associated compartment syndrome after fasciotomy Ebraheim, N. A.; Bedside fasciotomy under 2012 Journal of PICO 10: Fasciotomy insufficient data for Abdelgawad, A. A.; local anesthesia for acute Orthopaedics & Methods; PICO 15: Pain target outcomes Ebraheim, M. A.; Alla, S. compartment syndrome: a Traumatology Management R. feasible and reliable procedure in selected cases Airaksinen, O.; Kolari, P. Intracompartmental pressure 1991 Journal of PICO 11: Pre-op <20 patients; n16 J.; Heiskanen, J.; among patients suffering from Rehabilitation Adjunctive Therapy Rantanen, P. overuse symptoms in the Sciences upper extremity. Effect of intermittent pneumatic compression Brink, F.; Bachmann, S.; Mechanism of injury and 2014 European Journal of PICO 11: Pre-op insufficient data for Lechler, P.; Frink, M. treatment of trauma- Trauma & Adjunctive Therapy target outcomes associated acute Emergency Surgery compartment syndrome of the foot

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Chamogeorgakis, T.; Outcomes of axillary artery 2013 Journal of Thoracic PICO 11: Pre-op insufficient data for Lima, B.; Shafii, A. E.; side graft cannulation for and Cardiovascular Adjunctive Therapy target condition; 4 CS Nagpal, D.; Pokersnik, J. extracorporeal membrane Surgery A.; Navia, J. L.; Mason, oxygenation D.; Gonzalez-Stawinski, G. V. Clarke, W. T. Volkmann's ischemic 1945 University of Toronto PICO 11: Pre-op case reports contracture Medical Journal Adjunctive Therapy Clarke, W. T. Volkmann's ischaemic 1946 Canadian Medical PICO 11: Pre-op case reports contracture Association Journal Adjunctive Therapy Karch, M. M. Managing intra-articular 2001 Trauma PICO 11: Pre-op review fractures of the os calcis and Adjunctive Therapy associated injuries Kent, M. L.; Battlefield regional 2012 Techniques in PICO 11: Pre-op review Buckenmaier, C. C. anesthesia: Evolution and Regional Anesthesia Adjunctive Therapy future concepts and Pain Management Korambayil, P. M.; A multidisciplinary approach 2015 Toxicology PICO 11: Pre-op insufficient data for Ambookan, P. V.; with hyperbaric oxygen International Adjunctive Therapy target condition; no Abraham, S. V.; therapy improve outcome in fasciotomy Ambalakat, A. snake bite injuries Lavery, G. G.; Bhavsar, Critical care after major 2009 British Journal of PICO 11: Pre-op review M. trauma: We need to think Intensive Care Adjunctive Therapy beyond the unit Leonard, J.; Zietlow, J.; A multi-institutional study of 2016 Journal of Trauma PICO 11: Pre-op Insufficient data for Morris, D.; Berns, K.; hemostatic gauze and and Acute Care Adjunctive Therapy target condition; 0 CS Eyer, S.; Martinson, K.; tourniquets in rural civilian Surgery Jenkins, D.; Zietlow, S. trauma Passos, E.; Dingley, B.; Tourniquet use for peripheral 2014 Injury PICO 11: Pre-op Insufficient data for Smith, A.; Engels, P. T.; vascular injuries in the civilian Adjunctive Therapy target condition Ball, C. G.; Faidi, S.; setting Nathens, A.; Tien, H. Radonic, V.; Baric, D.; War injuries of the crural 1995 British Journal of PICO 11: Pre-op not best available Petricevic, A.; Kovacevic, arteries Surgery Adjunctive Therapy evidence

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion H.; Sapunar, D.; Glavina- Durdov, M.

Tay, A. K. L.; Complications associated with 2011 Sports Medicine and PICO 11: Pre-op review MacDonald, P. B. treatment of multiple ligament Arthroscopy Review Adjunctive Therapy injured (Dislocated) knee Fowler, J. R.; Kleiner, M. Assisted closure of fasciotomy 2012 Bone Joint Res PICO 12: Wound insufficient data for T.; Das, R.; Gaughan, J. wounds: A descriptive series Management target comparison P.; Rehman, S. and caution in patients with vascular injury Giannoudis, P. V.; The impact of lower leg 2002 Injury PICO 12: Wound Insufficient data for Nicolopoulos, C.; compartment syndrome on Management target condition Dinopoulos, H.; Ng, A.; health related quality of life Adedapo, S.; Kind, P. Govaert, G. A.; van Ty-raps in trauma: a novel 2010 Journal of Trauma- PICO 12: Wound insufficient data for Helden, S. closing technique of extremity Injury Infection & Management target comparison; no fasciotomy wounds Critical Care comparison grps Hake, M. E.; Etscheidt, Age and dressing type as 2017 International PICO 12: Wound Confounded J.; Chadayammuri, V. P.; independent predictors of Orthopaedics Management treatment Kirsch, J. M.; Mauffrey, post-operative infection in C. patients with acute compartment syndrome of the lower leg Kim, J. Y.; Buck, D. W., Risk factors for compartment 2009 Journal of Trauma- PICO 12: Wound insufficient data for 2nd; Forte, A. J.; syndrome in traumatic Injury Infection & Management target comparison Subramanian, V. S.; brachial artery injuries: an Critical Care Birman, M. V.; Schierle, institutional experience in 139 C. F.; Kloeters, O.; patients Mattox, K. L.; Wall, M. J.; Epstein, M. J. Labler, L.; Rancan, M.; Vacuum-assisted closure 2009 J Trauma PICO 12: Wound insufficient data for Mica, L.; Harter, L.; therapy increases local Management target condition Mihic-Probst, D.; Keel, interleukin-8 and vascular M. endothelial growth factor levels in traumatic wounds

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Matsen, F. A., 3rd; Veith, Compartmental syndromes in 1981 Journal of Pediatric PICO 12: Wound Insufficient data for R. G. children Orthopedics Management target comparison Matt, S. E.; Johnson, L. Management of fasciotomy 2011 Am Surg PICO 12: Wound not best available S.; Shupp, J. W.; wounds--does the dressing Management evidence Kheirbek, T.; Sava, J. A. matter? Price, G.; Hodgins, N.; A comparison of fasciotomy 2016 European Journal of PICO 12: Wound not best available Fogarty, B. wound closure methods Plastic Surgery Management evidence following extremity compartment syndrome at a regional trauma centre Ris, H. B.; Furrer, M.; Four-compartment fasciotomy 1993 Surgery PICO 12: Wound not best available Stronsky, S.; Walpoth, and venous calf-pump Management evidence B.; Nachbur, B. function: long-term results Walker, M.; Kralik, D.; Fasciotomy wounds 2014 JBI Database of PICO 12: Wound systematic review Porritt, K. associated with acute Systematic Reviews Management compartment syndrome: A and Implementation systematic review of effective Reports treatment Walker, T.; Gruler, M.; The use of a silicon sheet for 2012 Journal of Vascular PICO 12: Wound insufficient data for Ziemer, G.; Bail, D. H. gradual wound closure after Surgery Management target comparison fasciotomy Yoon, P. Late reconstruction for 2012 Techniques in PICO 12: Wound review sequelae of compartment Orthopaedics Management syndrome Allmon, C.; Greenwell, Radiographic Predictors of 2016 Journal of PICO 13: Associative insufficient data for P.; Paryavi, E.; Dubina, Compartment Syndrome Orthopaedic Trauma Fracture target condition A.; O'Toole, R. V. Occurring After Tibial Fracture Arnander, M. W. T.; Forearm fractures 2006 Surgery PICO 13: Associative review Newman, K. J. H. Fracture Banderker, M. A.; Civilian popliteal artery 2012 South African PICO 13: Associative Insufficient data for Navsaria, P. H.; Edu, S.; injuries Journal of Surgery Fracture target comparison Bekker, W.; Nicol, A. J.; Naidoo, N. Bartle, D.; Keating, J. Femoral and tibial fractures 2013 Surgery (United PICO 13: Associative review Kingdom) Fracture

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Beebe, M. J.; Auston, D.; OTA Classification is Highly 2017 Journal of PICO 13: Associative Insufficient data for Quade, J.; Serrano- Predictive of Acute Orthopaedic Trauma Fracture target comparison Riera, R.; Shah, A.; Compartment Syndrome Watson, D.; Sanders, R.; Following Tibia Fracture: A Mir, H. Cohort of 2885 Fractures Benns, M.; Miller, K.; Heroin-related compartment 2017 American Surgeon PICO 13: Associative insufficient data for Harbrecht, B.; Bozeman, syndrome: An increasing Fracture target comparison M.; Nash, N. problem for acute care surgeons Berg, R. J.; Okoye, O.; Extremity firearm trauma: The 2012 American Surgeon PICO 13: Associative Insufficient data for Inaba, K.; Konstantinidis, impact of injury pattern on Fracture target comparison A.; Branco, B.; Meisel, clinical outcomes E.; Barmparas, G.; Demetriades, D. Bhandari, M. Fluid lavage of open wounds 2010 BMC PICO 13: Associative pico not answered; no (FLOW): Design and rationale Musculoskeletal Fracture CS for a large, multicenter Disorders collaborative 2 Ã? 3 factorial trial of irrigating pressures and solutions in patients with open fractures Blackman, A. J.; Wall, L. Acute compartment syndrome 2014 Journal of Pediatric PICO 13: Associative insufficient data for B.; Keeler, K. A.; after intramedullary nailing of Orthopedics Fracture target condition; 3CS Schoenecker, P. L.; isolated radius and ulna Luhmann, S. J.; fractures in children O'Donnell, J. C.; Gordon, J. E. Blair, J. A.; Stoops, T. K.; Infection and Nonunion After 2016 Journal of PICO 13: Associative not best available Doarn, M. C.; Kemper, Fasciotomy for Compartment Orthopaedic Trauma Fracture evidence D.; Erdogan, M.; Griffing, Syndrome Associated With R.; Sagi, H. C. Tibia Fractures: A Matched Cohort Comparison Brandenburg, M. A.; Hand injuries, part 2: When 2005 Consultant PICO 13: Associative review Hawkins, L.; Quick, G. nerves, vasculature, tendons, Fracture or ligaments are traumatized

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Browne, H. S. Ischemic necrosis of muscle 1968 Rhode Island PICO 13: Associative case reports (acute anterior compartment Medical Journal Fracture syndrome) following repair of anterior compartment muscle hernias Buckley, S. L.; Smith, G.; Open fractures of the tibia in 1990 Journal of Bone & PICO 13: Associative insufficient data; 2 CS Sponseller, P. D.; children Joint Surgery - Fracture pts Thompson, J. D.; Griffin, American Volume P. P. Busch, T.; SÃ®rbu, H.; Vascular complications 1997 Thoracic and PICO 13: Associative Insufficient data for Zenker, D.; Dalichau, H. related to intraaortic balloon Cardiovascular Fracture target comparison; counterpulsation: An analysis Surgeon CS outcome of ten years experience Court-Brown, C. M.; Intramedullary nailing of tibial 2003 Injury PICO 13: Associative Insufficient data for Byrnes, T.; McLaughlin, diaphyseal fractures in Fracture target condition; 3 CS G. adolescents with open physes Court-Brown, C.; Compartment syndrome 1987 Acta Orthopaedica PICO 13: Associative insufficient data for McQueen, M. delays tibial union Scandinavica Fracture target condition; fracture fixation for ACS vs. non-ACS Crespo, A. M.; Manoli, Development of Compartment 2015 Journal of PICO 13: Associative cost analysis; A., 3rd; Konda, S. R.; Syndrome Negatively Impacts Orthopaedic Trauma Fracture incidence study Egol, K. A. Length of Stay and Cost After Tibia Fracture De Brito, D.; Challoner, The injury pattern of a new 2001 Annals of PICO 13: Associative insufficient data for K. R.; Sehgal, A.; Mallon, law enforcement weapon: The Emergency Medicine Fracture target condition; 2 CS W. police bean bag Dellon, A. L. Clinical use of vibratory stimuli 1980 Plastic and PICO 13: Associative insufficient data for to evaluate peripheral nerve Reconstructive Fracture target condition; 9 injury and decompression Surgery ACS neuropathy Donnan, L. T.; Saleh, M.; Acute correction of lower limb 2003 Journal of Bone and PICO 13: Associative pico not answered; no Rigby, A. S. deformity and simultaneous Joint Surgery - Fracture CS lengthening with a Series B monolateral fixator

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Dua, A.; Patel, B.; Desai, Comparison of military and 2014 Journal of Vascular PICO 13: Associative insufficient data for S. S.; Holcomb, J. B.; civilian popliteal artery trauma Surgery Fracture target comparison Wade, C. E.; Coogan, S.; outcomes Fox, C. J. Dubina, A. G.; Paryavi, Surgical site infection in tibial 2017 Injury PICO 13: Associative insufficient data for E.; Manson, T. T.; plateau fractures with Fracture target comparison Allmon, C.; O'Toole, R. ipsilateral compartment V. syndrome Dunkel, N.; Pittet, D.; Short duration of antibiotic 2013 Bone and Joint PICO 13: Associative insufficient data for Tovmirzaeva, L.; SuvÃ , prophylaxis in open fractures Journal Fracture target condition D.; Bernard, L.; Lew, D.; does not enhance risk of Hoffmeyer, P.; UÃ§kay, subsequent infection I. Egol, K. A.; Tejwani, N. Staged management of high- 2005 Journal of PICO 13: Associative insufficient data for C.; Capla, E. L.; energy proximal tibia fractures Orthopaedic Trauma Fracture target comparison Wolinsky, P. L.; Koval, K. (OTA types 41): the results of J. a prospective, standardized protocol Ferlic, P. W.; Singer, G.; The acute compartment 2012 Injury PICO 13: Associative not best available Kraus, T.; Eberl, R. syndrome following fractures Fracture evidence of the lower leg in children Firoozabadi, R.; Hyperextension Varus 2016 Journal of PICO 13: Associative Insufficient data for Schneidkraut, J.; Bicondylar Tibial Plateau Orthopaedic Trauma Fracture target comparison Beingessner, D.; Dunbar, Fracture Pattern: Diagnosis R.; Barei, D. and Treatment Strategies Fletcher, N. D.; Schiller, Increased severity of type III 2012 Journal of Pediatric PICO 13: Associative Insufficient data for J. R.; Garg, S.; Weller, supracondylar humerus Orthopaedics Fracture target condition A.; Larson, A. N.; Kwon, fractures in the preteen M.; Browne, R.; Copley, population L.; Ho, C. Flynn, J. M.; Jones, K. J.; Eleven years experience in 2010 Journal of Pediatric PICO 13: Associative Insufficient data for Garner, M. R.; Goebel, J. the operative management of Orthopaedics Fracture target condition; 3 CS pediatric forearm fractures Fogerty, S. J.; Fractures of the femoral shaft 2007 Surgery PICO 13: Associative review Giannoudis, P. V. Fracture

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Gaebler, C.; Berger, U.; Rates and odds ratios for 2001 Journal of PICO 13: Associative insufficient data for Schandelmaier, P.; complications in closed and Orthopaedic Trauma Fracture target condition Greitbauer, M.; open tibial fractures treated Schauwecker, H. H.; with unreamed, small Applegate, B.; Zych, G.; diameter tibial nails: A VÃ©csei, V. multicenter analysis of 467 cases Gamulin, A.; Lubbeke, Clinical and radiographic 2017 BMC PICO 13: Associative insufficient data for A.; Belinga, P.; predictors of acute Musculoskeletal Fracture target comparison Hoffmeyer, P.; Perneger, compartment syndrome in the Disorders T. V.; Zingg, M.; treatment of tibial plateau Cunningham, G. fractures: a retrospective cohort study Gershuni, D. H.; Fracture of the tibia 1987 Clinical PICO 13: Associative insufficient data for Mubarak, S. J.; Yaru, N. complicated by acute Orthopaedics & Fracture target comparison C.; Lee, Y. F. compartment syndrome Related Research Gibson, M. J.; Barnes, Weakness of foot dorsiflexion 1986 Journal of Bone & PICO 13: Associative insufficient data for M. R.; Allen, M. J.; Chan, and changes in compartment Joint Surgery - Fracture target condition R. N. pressures after tibial British Volume osteotomy Gitlitz, G. F. The Anterior Tibial 1965 Vascular Diseases PICO 13: Associative review; case reports Compartment Syndrome: A Fracture Complication of a Femoropopliteal Bypass Procedure Gonzalez, A.; SuvÃ , D.; Are there clinical variables 2014 International PICO 13: Associative insufficient data for Dunkel, N.; NicodÃ¨me, determining antibiotic Orthopaedics Fracture target comparison J. D.; Lomessy, A.; prophylaxis-susceptible Lauper, N.; Rohner, P.; versus resistant infection in Hoffmeyer, P.; UÃ§kay, open fractures? I. Grottkau, B. E.; Epps, H. Compartment syndrome in 2005 Journal of Pediatric PICO 13: Associative Insufficient data for R.; Di Scala, C. children and adolescents Surgery Fracture target comparison; incidence data Hahn, M.; Strauss, E.; Gunshot wounds to the 1995 Orthopedic Clinics of PICO 13: Associative review Yang, E. C. forearm North America Fracture

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Hall, M. M. Pros and cons of medical 1985 Journal of PICO 13: Associative review antishock trousers Emergency Nursing Fracture Haller, J. M.; Githens, Does Provisional Plating of 2017 Journal of PICO 13: Associative Insufficient data for M.; Scolaro, J.; Closed Tibia Fractures Have Orthopaedic Trauma Fracture target condition; 11 Firoozabadi, R. Higher Complication Rates? CS Haller, J. M.; Holt, D.; Does Early versus Delayed 2016 Clinical PICO 13: Associative insufficient data for Rothberg, D. L.; Kubiak, Spanning External Fixation Orthopaedics & Fracture target comparison; E. N.; Higgins, T. F. Impact Complication Rates for Related Research <10 per ACS group High-energy Tibial Plateau and Plafond Fractures? Heir, T. Musculoskeletal injuries in 1998 Military Medicine PICO 13: Associative incidence study officer training: One-year Fracture follow-up Henrikson, B. Supracondylar fracture of the 1966 Acta Chirurgica PICO 13: Associative Irrelevant topic; humerus in children. A late Scandinavica - Fracture fracture no ACS review of end-results with Supplementum special reference to the cause of deformity, disability and complications Herzog, G. A.; Serrano- Traumatic Proximal 2015 Journal of PICO 13: Associative insufficient data; 7 CS Riera, R.; Sagi, H. C. Tibiofibular Dislocation: A Orthopaedic Trauma Fracture pts Marker of Severely Traumatized Extremities Holliman, C. J.; Saffle, J. Early surgical decompression 1982 American Journal of PICO 13: Associative Insufficient data for R.; Kravitz, M.; Warden, in the management of Surgery Fracture target comparison G. D. electrical injuries Hopton, B. P.; Harris, N. Fractures of the foot and 2007 Surgery PICO 13: Associative review J. ankle Fracture Hopton, B. P.; Harris, N. Fractures of the foot and 2010 Surgery PICO 13: Associative review J. ankle Fracture Hunter, J. G.; A Comparative Analysis of the 2017 Techniques in Foot PICO 13: Associative Insufficient data for Baumhauer, J. F. Most Common Complications and Ankle Surgery Fracture target comparison for Patients Undergoing Traumatic Foot and Ankle Surgery

112

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Hwang, R. W.; de Witte, Compartment syndrome 2009 Journal of Bone & PICO 13: Associative pico not answered; P. B.; Ring, D. associated with distal radial Joint Surgery - Fracture risk assessment fracture and ipsilateral elbow American Volume injury Jacob, J. E. Vascular injuries in Vietnam. 1972 International Surgery PICO 13: Associative Insufficient data for With special reference to Fracture target condition; 3 compartment syndrome fasciotomy Kakar, S.; Firoozabadi, Diastolic blood pressure in 2007 Journal of PICO 13: Associative Insufficient data for R.; McKean, J.; Tornetta, patients with tibia fractures Orthopaedic Trauma Fracture target condition; no P., 3rd under anaesthesia: ACS implications for the diagnosis of compartment syndrome Kakar, S.; Tornetta, Iii P. Segmental tibia fractures: A 2007 Clinical PICO 13: Associative Insufficient data for prospective evaluation Orthopaedics and Fracture target condition; 6 CS Related Research KaradaÅ?, S.; The effects on complications 2011 Ulusal Travma ve PICO 13: Associative foreign language; risk GÃ¶nÃ¼llÃ¼, H.; and myopathy of different Acil Cerrahi Dergisi Fracture assessment Ã?ncÃ¼, M. R.; IÅ?ik, voltages in electrical injuries D.; Canbaz, Y. Kasotakis, G.; Sideris, Aggressive early crystalloid 2013 The Journal of PICO 13: Associative pico not answered; A.; Yang, Y.; de Moya, resuscitation adversely affects Trauma and Acute Fracture risk assessment M.; Alam, H.; King, D. R.; outcomes in adult blunt Care Surgery Tompkins, R.; Velmahos, trauma patients: an analysis G.; Inflammation,; Host of the Glue Grant database Response to Injury, Investigators Kim, J. W.; Oh, C. W.; Staged minimally invasive 2017 Injury PICO 13: Associative Insufficient data for Oh, J. K.; Kyung, H. S.; plate osteosynthesis of Fracture target comparison Park, K. H.; Kim, H. J.; proximal tibial fractures with Jung, J. W.; Jung, Y. S. acute compartment syndrome Knapp, M. E. Late treatment of fractures 1966 Postgraduate PICO 13: Associative review and complications. 2 Medicine Fracture Kugelman, D.; Qatu, A.; Complications and unplanned 2017 Injury PICO 13: Associative Insufficient data for Haglin, J.; Leucht, P.; outcomes following operative Fracture target condition; 6 CS Konda, S.; Egol, K. treatment of tibial plateau fractures

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion LÃ¸kse Nilssen, G. A.; Results of catheter-directed 2011 European Journal of PICO 13: Associative pico not answered; Svendsen, D.; Singh, K.; endovascular thrombolytic Vascular and Fracture CS outcome Nordhus, K.; SÃ¸rlie, D. treatment of acute ischaemia Endovascular of the leg Surgery Lakhwani, M. N.; Gooi, Vascular trauma in Penang 2002 Medical Journal of PICO 13: Associative insufficient data for B. H.; Barras, C. D. J. and Kuala Lumpur Hospitals Malaysia Fracture target comparison Lancourt, J. E.; Gilbert, Management of bleeding and 1977 Journal of Bone & PICO 13: Associative irrelevant topic; M. S.; Posner, M. A. associated complications of Joint Surgery - Fracture hemophilia hemophilia in the hand and American Volume forearm Liu, L.; Tang, X.; Pei, F. Treatment for 332 cases of 2010 Chinese Journal of PICO 13: Associative pico not answered; X.; Tu, C. Q.; Song, Y. lower leg fracture in "5.12" Traumatology Fracture CS outcome M.; Huang, F. G.; Yang, Wenchuan earthquake T. F.; Wang, G. L.; Fang, Y.; Zhang, H.; Zhong, G. Lowe, G.; Tait, C. Limb pain and swelling 2009 Medicine PICO 13: Associative review Fracture McQueen, M. Acute compartment syndrome 1998 Acta Chirurgica PICO 13: Associative review Belgica Fracture McQueen, M. M. Intramedullary reaming and 1996 Techniques in PICO 13: Associative review compartment pressure Orthopaedics Fracture McQueen, M. M.; Acute compartment 2000 Journal of Bone & PICO 13: Associative prevalence study; Gaston, P.; Court-Brown, syndrome. Who is at risk? Joint Surgery - Fracture various causes C. M. British Volume Min, L.; Burruss, S.; A simple clinical risk 2013 Journal of Trauma PICO 13: Associative pico not answered; Morley, E.; Mody, L.; nomogram to predict and Acute Care Fracture risk assessment Hiatt, J. R.; Cryer, H.; mortality-associated geriatric Surgery Ha, J. K.; Tillou, A. complications in severely injured geriatric patients Mishwani, A. H.; Ghaffar, Combat related vascular 2012 Journal of the PICO 13: Associative insufficient data for A.; Janjua, S. trauma College of Fracture target condition; 2 CS Physicians and Surgeons Pakistan

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Moed, B. R.; Fakhouri, A. Compartment syndrome after 1991 Journal of PICO 13: Associative Insufficient data for J. low-velocity gunshot wounds Orthopaedic Trauma Fracture target condition; 13 to the forearm CS Mohammad Naghi, T.; Musculoskeletal injuries 2005 Injury PICO 13: Associative duplicate of PMID Kambiz, K.; Shahriar, J. associated with earthquake: A Fracture 15589909 M.; Afshin, T.; Kamrani report of injuries of Iran's Reza, S.; Behnam, P.; December 26, 2003 Bam Harandi Bahador, A. earthquake casualties managed in tertiary referral centers Mohler, L. R.; Pedowitz, Pressure generation beneath 1996 Clinical PICO 13: Associative healthy participants R. A.; Byrne, T. P.; a new thermoplastic cast Orthopaedics & Fracture Gershuni, D. H. Related Research Naidu, S. H.; Capo, J. Upper extremity compartment 1997 Techniques in PICO 13: Associative review syndromes Orthopaedics Fracture Pandya, N. K.; Edmonds, Immediate intramedullary 2012 Journal of Pediatric PICO 13: Associative Insufficient data for E. W. flexible nailing of open Orthopaedics Fracture target condition; 4 CS pediatric tibial shaft fractures Pridgeon, S.; Bishop, C. Lower limb compartment 2013 BJU International PICO 13: Associative pico not answered; V.; Adshead, J. syndrome as a complication Fracture CS outcome of robot-assisted radical prostatectomy: the UK experience Radonic, V.; Budimir, D.; Envenomation by the horned 1997 Military Medicine PICO 13: Associative CS outcome; <10 Bradaric, N.; Luksic, B.; viper (Vipera ammodytes L.) Fracture ACS Sapunar, D.; Vilovic, K. Robertson, P.; Karol, L. Open fractures of the tibia 1996 Journal of Pediatric PICO 13: Associative insufficient data; <10 A.; Rab, G. T. and femur in children Orthopedics Fracture CS pts Rosenfield, A. L.; Orthopedic injuries from the 1994 Journal of Trauma PICO 13: Associative Incidence rates and McQueen, D. A.; Lucas, Andover, Kansas, Tornado Fracture case reports G. L. Ruoff, G. Trigger point injections: A 2003 Consultant PICO 13: Associative review primary care intervention Fracture

115

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Sanford, A.; Gamelli, R. Lightning and thermal injuries 2014 PICO 13: Associative review L. Fracture Scerbo, M. H.; Mumm, J. Safety and Appropriateness 2016 Prehospital PICO 13: Associative insufficient data; 2 CS P.; Gates, K.; Love, J. of Tourniquets in 105 Civilians Emergency Care Fracture pts D.; Wade, C. E.; Holcomb, J. B.; Cotton, B. A. Scheel, A. K.; Toepfer, Ultrasonographic Assessment 1997 Journal of PICO 13: Associative insufficient data for M.; Kunkel, M.; of the Prevalence of Neuroimaging Fracture target condition; 3 CS Finkenstaedt, M.; Fasciculations in Lesions of Reimers, C. D. the Peripheral Nervous System Shadgan, B.; Pereira, G.; Risk factors for acute 2015 Journal of PICO 13: Associative insufficient data for Menon, M.; Jafari, S.; compartment syndrome of the Orthopaedics & Fracture target comparison Darlene Reid, W.; leg associated with tibial Traumatology O'Brien, P. J. diaphyseal fractures in adults Shore, B. J.; Acute compartment syndrome 2013 Journal of PICO 13: Associative insufficient data for Glotzbecker, M. P.; in children and teenagers with Orthopaedic Trauma Fracture target comparison Zurakowski, D.; Gelbard, tibial shaft fractures: E.; Hedequist, D. J.; incidence and multivariable Matheney, T. H. risk factors Stanish, W. D. Lower leg, foot, and ankle 1995 Clinics in Sports PICO 13: Associative review injuries in young athletes Medicine Fracture

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Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Tahmasebi, M. N.; Kiani, Musculoskeletal injuries 2005 Injury PICO 13: Associative Insufficient data for K.; Mazlouman, S. J.; associated with earthquake. A Fracture target comparison Taheri, A.; Kamrani, R. report of injuries of Iran's S.; Panjavi, B.; Harandi, December 26, 2003 Bam B. A. earthquake casualties managed in tertiary referral centers.[Erratum appears in Injury. 2005 Jun;36(6):810 Note: Mohammad Naghi, Tahmasebi [corrected to Tahmasebi, Mohammad Naghi]; Kambiz, Kiani [corrected to Kiani, Kambiz]; Shahriar, Jalali Mazlouman [corrected to Mazlouman, Shahriar Jalali]; Afshin, Taheri [corrected to Taheri, Afshin]; Kamrani Reza, Shahriar [corrected to Kamrani, Reza Sha Tao, X.; Chen, N.; Pan, External fixation combined 2017 Medicine (United PICO 13: Associative insufficient data for F.; Cheng, B. with delayed internal fixation States) Fracture target condition; 2 CS in treatment of tibial plateau fractures with dislocation Thabet, A. M.; Simson, J. The impact of acute 2017 European journal of PICO 13: Associative Insufficient data for E.; Gerzina, C.; Dabash, compartment syndrome on orthopaedic surgery Fracture target comparison S.; Adler, A.; the outcome of tibia plateau & traumatologie Abdelgawad, A. A. fracture Topal, A. E.; Eren, M. N.; Lower extremity arterial 2010 Vascular Health and PICO 13: Associative pico not answered; Celik, Y. injuries over a six-year period: Risk Management Fracture risk assessment Outcomes, risk factors, and management Tremblay, L. N.; Secondary extremity 2002 Journal of Trauma- PICO 13: Associative Insufficient data for Feliciano, D. V.; Rozycki, compartment syndrome Injury Infection & Fracture target comparison G. S. Critical Care

117

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Turen, C. H.; Burgess, A. Skeletal stabilization for tibial 1995 Clinical PICO 13: Associative not best available R.; Vanco, B. fractures associated with Orthopaedics & Fracture evidence acute compartment syndrome Related Research Tytherleigh-Strong, G. Extra-articular fractures of the 1997 Journal of the Royal PICO 13: Associative Insufficient data for M.; Keating, J. F.; Court- proximal tibial diaphysis: Their College of Surgeons Fracture target condition; 2 Brown, C. M. epidemiology, management of Edinburgh ACS and outcome Vrouenraets, B. C.; Regional toxicity after isolated 2001 European Journal of PICO 13: Associative insufficient data for Eggermont, A. M. M.; limb perfusion with melphalan Surgical Oncology Fracture target condition Hart, A. A. M.; Klaase, J. and tumour necrosis factor-Î± M.; Van Geel, A. N.; versus toxicity after Nieweg, O. E.; Kroon, B. melphalan alone B. R. Wang, E.; Inaba, K.; Do antiplatelet and 2016 American Surgeon PICO 13: Associative Insufficient data for Cho, J.; Byerly, S.; anticoagulation agents matter Fracture target condition; 4 CS Rowe, V.; Benjamin, E.; after repair of traumatic Lam, L.; Demetriades, D. arterial injuries? Wolpert, L. M.; Dittrich, Vascular problems in the 2000 Problems in General PICO 13: Associative review K. P.; Windels, M. H.; intensive care unit Surgery Fracture Drezner, A. D. Yusof, N. M.; Oh, C. W.; Percutaneous plating in 2009 Injury PICO 13: Associative <20 patients; n16 Oh, J. K.; Kim, J. W.; paediatric tibial fractures Fracture Min, W. K.; Park, I. H.; Kim, H. J. Zachary, L. M.; Lee, R. Evolving clinical and scientific 1990 Hand Clinics PICO 13: Associative review C.; Gottlieb, L. J. concepts of upper extremity Fracture electrical trauma Zorrilla, S. de Neira J.; Supracondylar humeral 2015 International PICO 13: Associative review Prada-CaÃ±izares, A.; fractures in children: current Orthopaedics Fracture Marti-Ciruelos, R.; concepts for management Pretell-Mazzini, J. and prognosis

118

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Zura, R. D.; Adams, S. Timing of definitive fixation of 2010 Journal of Trauma- PICO 13: Associative not best available B., Jr.; Jeray, K. J.; severe tibial plateau fractures Injury Infection & Fracture evidence Obremskey, W. T.; with compartment syndrome Critical Care Stinnett, S. S.; Olson, S. does not have an effect on A.; Southeastern the rate of infection Fracture Consortium, Foundation Matsen, F. A., 3rd; Mayo, Monitoring of intramuscular 1976 Surgery PICO 13: Associative review K. A.; Sheridan, G. W.; pressure Fracture; PICO 11: Pre- Krugmire, R. B., Jr. op Adjunctive Therapy Rosenthal, R.; Sequelae of underdiagnosed 2013 Journal of Foot & PICO 13: Associative Insufficient data for Tenenbaum, S.; Thein, foot compartment syndrome Ankle Surgery Fracture; PICO 14: Foot target condition; 5 CS R.; Steinberg, E. L.; after calcaneal fractures ACS Luger, E.; Chechik, O. Mabee, J. R.; Shean, C.; The effects of simulated Bier 1997 Acta PICO 13: Associative <20 patients; n7 Orlinsky, M.; Androy, L.; block IVRA on Anaesthesiologica Fracture; PICO 15: Pain healthy Carter, V. intracompartmental tissue Scandinavica Management pressure Wang, X.; Ma, X.; Zhang, Ankle fusion with a retrograde 2012 Chinese Journal of PICO 13: Associative pico not answered; tx C.; Huang, J. Z.; Gu, X. locked intramedullary nail for Traumatology Fracture; PICO 3: of post CS ankle J.; Jiang, J. Y. sequela of lower extremity Fasciotomy Missed ACS deformity compartment syndrome Woll, T. S.; Duwelius, P. The segmental tibial fracture 1992 Clinical PICO 13: Associative insufficient data for J. Orthopaedics & Fracture; PICO 6: target comparison Related Research Pressure Methods David, A.; Lewandrowski, Surgical correction of talipes 1996 Foot & Ankle PICO 14: Foot ACS Insufficient data for K. U.; Josten, C.; equinovarus following foot International target condition Ekkernkamp, A.; and leg compartment Clasbrummel, B.; Muhr, syndrome G. Smith, G. H. Measurement of the 1990 Journal of Foot PICO 14: Foot ACS <20 patients; n10 intracompartmental pressures Surgery of the foot

119

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Wei, N.; Yuwen, P.; Liu, Operative versus 2017 Medicine (United PICO 14: Foot ACS systematic review W.; Zhu, Y.; Chang, W.; nonoperative treatment of States) Feng, C.; Chen, W. displaced intra-articular calcaneal fractures: A meta- analysis of current evidence base Yoon, P. Compartment syndrome of 2012 Techniques in PICO 14: Foot ACS review the foot Orthopaedics Auroy, Y.; Narchi, P.; Serious complications related 1997 Anesthesiology PICO 15: Pain irrelevant topic; Messiah, A.; Litt, L.; to regional anesthesia: results Management regional anesthesia Rouvier, B.; Samii, K. of a prospective survey in France Black, K. J.; Bevan, C. Nerve blocks for initial pain 2013 Cochrane Database PICO 15: Pain systematic review; no A.; Murphy, N. G.; management of femoral of Systematic Management ACS Howard, J. J. fractures in children Reviews Bratt, H. D.; Eyres, R. L.; Randomized double-blind trial 1996 J Pediatr Orthop PICO 15: Pain irrelevant topic; Cole, W. G. of low- and moderate-dose Management forearm fracture lidocaine regional anesthesia for forearm fractures in childhood Ganapathy, S. Continuous nerve blocks for 2002 Techniques in PICO 15: Pain systematic review orthopedic injuries Regional Anesthesia Management and Pain Management Guay, J. Adverse events associated 2009 Journal of Clinical PICO 15: Pain systematic review with intravenous regional Anesthesia Management anesthesia (Bier block): a systematic review of complications Lonnqvist, P. A.; Ecoffey, The European society of 2017 Current Opinion in PICO 15: Pain systematic review C.; Bosenberg, A.; regional anesthesia and pain Anaesthesiology Management Suresh, S.; Ivani, G. therapy and the American society of regional anesthesia and pain medicine joint committee practice advisory on controversial topics in

120

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion pediatric regional anesthesia I and II: what do they tell us?

Maletis, G. B.; Watson, Compartment syndrome. A 1989 Orthopedics PICO 15: Pain insufficient data for R. C.; Scott, S. complication of intravenous Management target condition regional anesthesia in the reduction of lower leg shaft fractures Soni, S.; Johannson, H. Does regional anaesthesia in 2013 British Journal of PICO 15: Pain review trauma patients lead to Hospital Medicine Management delayed recognition of compartment syndrome? Boezeman, R. P.; Moll, Systematic review of clinical 2016 Microvascular Systematic Reviews systematic review F. L.; Unlu, C.; de Vries, applications of monitoring Research J. P. muscle tissue oxygenation with near-infrared spectroscopy in vascular disease Garcia-Covarrubias, L.; Adjuvant hyperbaric oxygen 2005 American Surgeon Systematic Reviews systematic review McSwain, N. E., Jr.; Van therapy in the management of Meter, K.; Bell, R. M. crush injury and traumatic ischemia: an evidence-based approach Glass, G. E.; Staruch, R. Managing missed lower 2016 The Journal of Systematic Reviews systematic review M.; Simmons, J.; Lawton, extremity compartment Trauma and Acute G.; Nanchahal, J.; Jain, syndrome in the Care Surgery A.; Hettiaratchy, S. P. physiologically stable patient: A systematic review and lessons from a Level I trauma center

121

Authors Article Title Year Expanded Recommendations Reason for Periodical Title Exclusion Kakagia, D. How to Close a Limb 2015 International Journal Systematic Reviews systematic review Fasciotomy Wound: An of Lower Extremity Overview of Current Wounds Techniques Kalyani, B. S.; Fisher, B. Compartment syndrome of 2011 Journal of Hand Systematic Reviews systematic review E.; Roberts, C. S.; the forearm: a systematic Surgery - American Giannoudis, P. V. review Volume Mar, G. J.; Barrington, M. Acute compartment syndrome 2009 British Journal of Systematic Reviews systematic review J.; McGuirk, B. R. of the lower limb and the Anaesthesia effect of postoperative analgesia on diagnosis Ojike, N. I.; Roberts, C. Foot compartment syndrome: 2009 Acta Orthopaedica Systematic Reviews systematic review S.; Giannoudis, P. V. a systematic review of the Belgica literature Ojike, N. I.; Roberts, C. Compartment syndrome of 2010 Injury Systematic Reviews systematic review S.; Giannoudis, P. V. the thigh: a systematic review Tiwari, A.; Haq, A. I.; Acute compartment 2002 British Journal of Systematic Reviews systematic review Myint, F.; Hamilton, G. syndromes Surgery Wall, C. J.; Lynch, J.; Clinical practice guidelines for 2010 ANZ Journal of Systematic Reviews systematic review Harris, I. A.; Richardson, the management of acute Surgery M. D.; Brand, C.; Lowe, limb compartment syndrome A. J.; Sugrue, M.; following trauma Liverpool,; Royal Melbourne, Hospitals

122 APPENDIX III - GUIDELINE DEVELOPMENT GROUP DISCLOSURES Prior to the development of this clinical practice guideline, clinical practice guideline development group members disclose conflicts of interest (COI). They disclose COIs in writing to the American Academy of Orthopaedic Surgeons via a private on-line reporting database and also verbally at the recommendation approval meeting.

Disclosure Items: (n) = Respondent answered 'No' to all items indicating no conflicts. 1 = Royalties from a company or supplier; 2 = Speakers bureau/paid presentations for a company or supplier; 3A = Paid employee for a company or supplier; 3B = Paid consultant for a company or supplier; 3C = Unpaid consultant for a company or supplier; 4 = Stock or stock options in a company or supplier; 5 = Research support from a company or supplier as a PI; 6 = Other financial or material support from a company or supplier; 7 = Royalties, financial or material support from publishers; 8 = Medical/Orthopaedic publications editorial/governing board; 9 = Board member/committee appointments for a society.

VOTING MEMBERS’ AND NON-VOTING OVERSIGHT CHAIRS’ DISCLOSURES

Work Group – Voting Members Anthony E Johnson, MD Submitted on: 08/15/2017 AAOS: Board or committee member ($0) Multiple Committees(Self) Arthroscopy: Editorial or governing board ($0) N/A(Self) Chief Editor, Medscape Orthopedics - Drugs & Diseases: Editorial or governing board ($250) N/A(Self) Clinical Orthopaedics and Related Research: Editorial or governing board ($0) N/A(Self) Consultant, Orthopaedic Devices Panel, US Food & Drug Administration: Paid consultant ($1,200) Reim bursed for Travel and Housing for panel meetings(Self) Foot and Ankle International: Editorial or governing board ($0) N/A(Self) Journal of Bone and Joint Surgery - British: Editorial or governing board ($0) N/A(Self) Journal of Surgery: Editorial or governing board ($0) N/A(Self) Pfizer: Stock or stock Options Number of Shares: 2,060 Stocks and Mutual Funds for General Investment. Will not have affect on CPG Working Group. Did not affect OA CPG Working Group for DoD/VA which just published. (Both) Society of Military Orthopaedic Surgeons: Board or committee member ($0) Immediate Past President & Member, Board of Directors (Self)

Patrick M Osborn, MD Submitted on: 11/10/2017 AAOS: Board or committee member American Orthopaedic Association: Board or committee member Perspectives in Medical Education: Editorial or governing board SAMMC Alumni Association: Board or committee member

Andrew H Schmidt, MD Submitted on: 10/07/2017 ActivOrtho: Stock or stock Options Number of Shares: 0 Acumed, LLC: Paid consultant ($0) Conventus Orthopaedics: Stock or stock Options Number of Shares: 0 Conventus Orthopedics: Paid consultant ($0) Epien: Stock or stock Options Number of Shares: 0 Epix VAN: Stock or stock Options Number of Shares: 0 JBJS Essential Surgical Techniques: Editorial or governing board ($0) Journal of Knee Surgery: Editorial or governing board ($0)

122 Journal of Orthopaedic Trauma: Editorial or governing board ($0) Smith & Nephew: IP royalties ($4,000) Design Proximal Femoral Plates(Self) St. Jude Medical: Paid consultant ($0) Thieme, Inc.: Publishing royalties, financial or material support ($0) Twin Star Medical: Stock or stock Options Number of Shares: 0

Luke H Balsamo, MD (This individual reported nothing to disclose); Submitted on: 10/17/2017

Marcus Philip Coe, MD Submitted on: 04/07/2017 Ferring Pharmaceuticals: Research support ($0) footeducation.com: Editorial or governing board ($0)

I. Leah Gitajn, MD (This individual reported nothing to disclose); Submitted on: 10/10/2017

Renee Greer, RN, BSN (This individual reported nothing to disclose); Submitted on: 11/13/2017

Moderators – Non-Voting Members Julie B Samora, MD Submitted on: 10/06/2017 AAOS: Board or committee member ($0) American Society for Surgery of the Hand: Board or committee member ($0) Ruth Jackson Orthopaedic Society: Board or committee member ($0)

David S Jevsevar, MD, MBA Submitted on: 10/03/2018 American Association of Hip and Knee Surgeons: Board or committee member ($0) EBPC(Self) DePuy, A Johnson & Johnson Company: Research support ($110,000) Institutional support clinical resear ch protocl(Self) MedScape: Paid presenter or speaker ($2,500) Number of Presentations: 1 MedScape(Self)

123 APPENDIX IV – PICO QUESTIONS USED TO DEFINE LITERATURE SEARCH

1. For patients with suspected extremity compartment syndrome, are there biomarkers (single or combined) which assist in diagnosing acute compartment syndrome? 2. For patients with missed/late extremity compartment syndrome, can biomarkers determine relative need/timing of fasciotomy? 3. For patients with missed/late extremity compartment syndrome, what is the benefit/harm to performing a fasciotomy? 4. For patients with suspected extremity compartment syndrome, does intramuscular pressure monitoring assist in diagnosing (precision, timing of surgery) acute compartment syndrome? 5. For patients with missed/late extremity compartment syndrome, can pressure monitoring determine relative need/timing of fasciotomy? 6. What is optimum method to measure compartment pressure? 7. For patients with suspected extremity compartment syndrome, are there alternative diagnostic modalities which assist in diagnosing acute compartment syndrome? 8. For awake patients with suspected extremity compartment syndrome, are there individual and/or combined physical exam findings which assist in diagnosing acute compartment syndrome? 9. For obtunded patients with suspected extremity compartment syndrome, are there individual and/or combined physical exam findings which assist in diagnosing acute compartment syndrome? 10. For patients with acute compartment syndrome, which fasciotomy methods best optimize patient outcomes? 11. For patients with suspected acute compartment syndrome, which adjunctive therapies show effectiveness in stabilizing patients prior to fasciotomy? 12. For patients who undergo fasciotomy for acute compartment syndrome, which wound management techniques result in improved patient outcomes? 13. For patients with acute compartment syndrome and an associative fracture, which fracture management techniques result in improved outcomes? 14. Should fasciotomy be done in foot? If so, which compartments should be checked/released? 15. Does method of pain management affect clinical diagnosis?

124 APPENDIX V – STUDY ATTRITION FLOW CHART

3607 abstracts reviewed, final search performed on March 6, 2018

3120 articles excluded from title and abstract review

482 articles recalled from abstract review

462 articles excluded after full text review for not meeting the inclusion criteria or not best available evidence

20 articles included after full text review and quality analysis

125 APPENDIX VI – LITERATURE SEARCH STRATEGY Database: MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Daily and MEDLINE (1946 to Present) Interface: Ovid Date searched: March 6, 2018 LINE SEARCH SYNTAX #1 compartment syndromes/ or exp anterior compartment syndrome/ or exp ischemic contracture/ #2 (acute adj3 compartment syndrome?).ab,ti. #3 (animals not humans).sh. #4 cadaver.sh. or cadaver*.ti. #5 (comment or editorial or letter or historical article or addresses or news or newspaper article or case reports).pt or case report.ti. #6 3 or 4 or 5 #7 1 or 2 #8 7 not 6 #9 limit 8 to English language

Database: Embase Interface: Embase.com (Elsevier) Date searched: March 6, 2018 LINE SEARCH SYNTAX #1 ((acute NEAR/3 compartment):ab,ti) AND ((compartment NEXT/2 syndrome*):ab,ti) #2 'acute compartment syndrome'/exp OR 'compartment syndrome'/de #3 'cadaver'/de OR 'in vitro study'/exp OR 'animal experiment'/de OR 'animal model'/de OR 'nonhuman'/de OR 'abstract report'/de OR 'book'/de OR 'editorial'/de OR 'note'/de OR 'letter'/de OR 'case study'/de OR 'case report'/de OR 'conference abstract'/it OR 'chapter'/it OR 'medical record review'/de OR 'conference paper'/it OR 'conference review'/it OR 'editorial'/it OR 'letter'/it OR 'note'/it #4 (#1 OR #2) NOT #3 AND [English]/lim

Database: Cochrane Central Register of Controlled Trials (CENTRAL) Interface: Wiley Date searched: March 6, 2018 SEARCH QUERY #1 MeSH descriptor: [Compartment Syndromes] this term only #2 MeSH descriptor: [Anterior Compartment Syndrome] explode all trees #3 MeSH descriptor: [Ischemic Contracture] explode all trees #4 "compartment syndrome":ti,ab and "acute":ti,ab #5 "conference abstract":pt #6 (#1 or #2 or #3 or #4) not #5 in Cochrane Reviews (Reviews and Protocols) and Trials

126 INCLUSION CRITERIA

• Study must be of monitoring or diagnosis of acute compartment syndrome– Are there any exceptions (e.g. Are we concerned with treatment?) • Study must be published in or after • Study should have 10 or more patients per group (Work group may further define sample size) • For surgical treatment a minimum of (no limit) 0 month follow up duration. • For non-operative treatment a minimum of (no limit) 0 month follow-up.

STANDARD CRITERIA FOR ALL CPGS

• Article must be a full article report of a clinical study (studies using registry data can be included in a guideline if it is published in a peer-reviewed journal and meets all other inclusion criteria/quality standards). • Retrospective non-comparative case series, medical records review, meeting abstracts, historical articles, editorials, letters, and commentaries are excluded. • Confounded studies (i.e. studies that give patients the treatment of interest AND another treatment) are excluded. • Case series studies that have non-consecutive enrollment of patients are excluded. • Controlled trials in which patients were not stochastically assigned to groups AND in which there was either a difference in patient characteristics or outcomes at baseline AND where the authors did not statistically adjust for these differences when analyzing the results are excluded. • All studies of “Very Weak” strength of evidence are excluded. • All studies evaluated as Level V will be excluded. • Composite measures or outcomes are excluded even if they are patient-oriented. • Study must appear in a peer-reviewed publication • For any included study that uses “paper-and-pencil” outcome measures (e.g., SF-36), only those outcome measures that have been validated will be included • For any given follow-up time point in any included study, there must be ≥ 50% patient follow-up (if the follow-up is >50% but <80%, the study quality will be downgraded by one Level) • Study must be of humans • Study must be published in English • Study results must be quantitatively presented • Study must not be an in vitro study • Study must not be a biomechanical study • Study must not have been performed on cadavers

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We will only evaluate surrogate outcomes when no patient-oriented outcomes are available.

Best Available Evidence When examining primary studies, we will analyze the best available evidence regardless of study design. We will first consider randomized controlled trials identified by the search strategy. In the absence of two or more RCTs, we will sequentially search for prospective controlled trials, prospective comparative studies, retrospective comparative studies, and prospective case-series studies. Only studies of the highest level of available evidence are included, assuming that there were 2 or more studies of that higher level. For example, if there are two high quality studies that address the recommendation, moderate and low studies addressing the same procedure and outcomes are not included.

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APPENDIX VII – PARTICIPATING PEER REVIEW ORGANIZATIONS • Orthopaedic Trauma Association (OTA) • American Orthopaedic Foot and Ankle Society (AOFAS) • American College of Surgeons (ACS)

129 LETTERS OF ENDORSEMENT FROM EXTERNAL ORGANIZATIONS

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December 17, 2018

Kaitlyn S. Sevarino, MBA Manager, Quality and Value Implementation Department of Research, Quality, & Scientific Affairs American Academy of Orthopaedic Surgeons 9400 West Higgins Road Rosemont, IL 60018

Dear Ms. Sevarino:

The American College of Surgeons has voted to endorse the AAOS Management of Acute Compartment Syndrome Clinical Practice Guideline. This endorsement implies permission for the AAOS to officially list our organization as an endorser of this clinical practice guideline and reprint our logo in the introductory section of the clinical practice guideline review document. Sincerely,

David B. Hoyt, MD, FACS Executive Director American College of Surgeons

DBH/dmc Attachment (ACS Logo included)

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January 17, 2019

Kaitlyn S. Sevarino, MBA Manager, Quality and Value Implementation Department of Research, Quality, & Scientific Affairs

Dear Ms. Sevarino,

The American Orthopaedic Foot & Ankle Society has voted to endorse the AAOS Management of Acute Compartment Syndrome Clinical Practice Guideline. This endorsement implies permission for the AAOS to officially list our organization as an endorser of this clinical practice guideline and reprint our logo in the introductory section of the clinical practice guideline review document.

Sincerely,

J. Chris Coetzee, MD AOFAS President

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