What imaging should I do to assess for compartment syndrome?

From the Guidelines

Compartment syndrome is primarily a clinical diagnosis, and imaging studies are not typically the first-line approach for assessment, with the gold standard for diagnosis being direct measurement of compartment pressures using a pressure monitor or manometer 1. When it comes to assessing for compartment syndrome, the focus should be on clinical findings and direct measurement of compartment pressures. The clinical signs to look out for include pain out of proportion to injury, pain on passive stretch, paresthesia, paralysis, and pallor.

Key Points to Consider

• Clinical diagnosis is the primary approach for assessing compartment syndrome, with a focus on clinical signs such as pain, paresthesia, and paralysis 1.
• Direct measurement of compartment pressures is the gold standard for diagnosis, using equipment such as a pressure monitor or manometer 1.
• Imaging studies, if needed, should not delay treatment if clinical suspicion is high, as compartment syndrome is a surgical emergency requiring prompt fasciotomy to prevent permanent tissue damage.
• MRI is the most sensitive modality for detecting muscle edema, altered perfusion, and compartmental swelling, but it should not replace clinical diagnosis and direct pressure measurement 1.
• Other imaging modalities like CT scans and ultrasound may have limited utility but can help rule out other causes of pain or demonstrate decreased muscle contractility or altered blood flow in affected compartments.

Recommendations for Practice

• Prioritize clinical assessment and direct measurement of compartment pressures over imaging studies for the diagnosis of compartment syndrome 1.
• Use imaging studies judiciously, considering the clinical context and the potential for delayed treatment.
• Be aware of the limitations and potential biases of different diagnostic approaches, including clinical signs, direct pressure measurement, and imaging studies.

From the Research

Imaging for Compartment Syndrome

• In the acute setting, there is little place for imaging in diagnosing compartment syndrome, as the diagnosis should be made on clinical grounds, possibly supported by measurements of compartmental pressure 2.
• However, imaging techniques such as MR imaging can be useful in diagnosing manifest compartment syndrome in clinically ambiguous cases, and can help identify the affected compartments 3.
• MR imaging can show swollen compartments with loss of normal muscle architecture on T1-weighted spin-echo images, and bright areas on T2-weighted spin-echo and magnetization transfer imaging that enhance after gadopentetate dimeglumine (Gd-DTPA) administration 3.
• Other imaging modalities such as ultrasound and infrared spectroscopy can also provide additional information to support decision-making in the diagnosis of acute compartment syndrome 4.
• MRI can also be used to diagnose acute bilateral compartment syndrome, as demonstrated in a case report where MRI led to the diagnosis of an acute bilateral compartment syndrome in a patient with bilateral paresis of the foot jack 5.

Specific Imaging Modalities

• MR imaging: can help make the diagnosis of a manifest compartment syndrome in clinically ambiguous cases, and can help identify the affected compartments 3, 5.
• Ultrasound: can provide additional information to support decision-making in the diagnosis of acute compartment syndrome 4.
• Infrared spectroscopy: can provide additional information to support decision-making in the diagnosis of acute compartment syndrome 4.