Education
Reg Anesth Pain Med: first published as 10.1136/rapm-2021-102735 on 29 June 2021. Downloaded from http://rapm.bmj.com/ on March 3, 2022 at Post Graduate Institute of Medical
1
Department of Surgery,
University of Toronto Division of
Orthopaedics, Toronto, Ontario,
Canada
2
Department of Surgery,
Women’s College Hospital,
Toronto, Ontario, Canada
3
Department of Surgery, Mt
Sinai Hospital, Toronto, Ontario,
Canada
4
University of Toronto Division
of Orthopaedics, Toronto,
Ontario, Canada
5
Department of Surgery, St
Michael’s Hospital, Toronto,
Ontario, Canada
6
Toronto Western Hospital,
Toronto, Ontario, Canada
Correspondence to
Dr Tim Dwyer, Department of
Surgery, University of Toronto,
Division of Orthopaedics,
Women’s College Hospital, 76
Grenville St, Toronto M5S1B2,
Canada;
​tim.​dwyer@w ​ chospital.​ca
Received 23 March 2021
Accepted 10 May 2021
Published Online First
29 June 2021
© American Society of Regional
Anesthesia & Pain Medicine
2021. No commercial re-­use.
See rights and permissions.
Published by BMJ.
To cite: Dwyer T,
Burns D, Nauth A, et al.
Reg Anesth Pain Med
2021;46:1091–1099.
Regional anesthesia and acute compartment
syndrome: principles for practice
Tim Dwyer,1,2,3 David Burns,4 Aaron Nauth,1,5 Kaitlin Kawam,4 Richard Brull  ‍ ‍6
ABSTRACT
Acute compartment syndrome (ACS) is a potentially
reversible orthopedic surgical emergency leading to
tissue ischemia and ultimately cell death. Diagnosis of
ACS can be challenging, as neither clinical symptoms
nor signs are sufficiently sensitive. The cardinal symptom
associated with ACS is pain reported in excess of what
would otherwise be expected for the underlying injury,
and not reasonably managed by opioid-­based analgesia.
Regional anesthesia (RA) techniques are traditionally
discouraged in clinical settings where the development
of ACS is a concern as sensory and motor nerve blockade
may mask symptoms and signs of ACS. This Education
article addresses the most common trauma and elective
orthopedic surgical procedures in adults with a view
towards assessing their respective risk of ACS and
offering suggestions regarding the suitability of RA for
each type of surgery.
INTRODUCTION
Acute compartment syndrome (ACS) is a critical
and potentially reversible orthopedic surgical emer-
gency, whereby excessive limb swelling (bleeding,
edema, or other fluid) within a myofascial compart-
ment compromises tissue perfusion leading to
tissue ischemia and ultimately cell death. Once
tissue perfusion is sufficiently compromised to
cause muscle death and permanent nerve injury,
significant loss of function due to muscle contrac-
ture, stiffness and deformity likely ensues,1 which
can be further complicated by high rates of infec-
tion, repeat surgery,2 amputation,3 4 and mortality.5
While the time after which permanent muscle and
nerve damage occurs is not clear, irreversible isch-
emic injury may begin as soon as 2 hours following
the onset of swelling.6 The longer the delay to
treatment, the more devastating the sequelae.4 The
possibility of ACS must therefore be anticipated,
and early intervention in the form of surgical fasci-
otomy must take priority when ACS is suspected or
imminent.7
Unfortunately, the diagnosis of ACS can be chal-
lenging, as neither clinical symptoms nor signs
are sufficiently sensitive for ACS.8 Moreover, the
clinical symptoms and signs associated with ACS
are common to many types of orthopedic injuries
that are traditionally not associated with ACS.9
The cardinal symptom associated with ACS is pain
reported in excess of what would otherwise be
expected for the underlying injury, and not reason-
ably managed by opioid-­based analgesia. Signs asso-
ciated with ACS include excessive tightness of the
affected compartment, pain with passive stretch
Dwyer T, et al. Reg Anesth Pain Med 2021;46:1091–1099. doi:10.1136/rapm-2021-102735
of the affected compartment, and paresthesia due
to ischemia of the entrapped peripheral nerves.10
Compartment pressure testing and monitoring can
be useful in confirming the diagnosis, with pain and
ischemia thought to develop at pressures greater
than 20 and 30 mm Hg, respectively.11 However,
the latter threshold values are variable, and can be
seen in patients with and without ACS.12–14 Due to
these variations, it is recommended that compart-
ment pressure values alone should not be used to
diagnose ACS.15
REGIONAL ANESTHESIA AND ACS
The use of regional anesthesia (RA) techniques for
Education & Research. Protected by copyright.
local anesthetic-­based anesthesia and analgesia has
traditionally been discouraged in clinical settings
where the development of ACS is a concern.
Prolonged sensory and motor nerve blockade can
complicate timely and accurate clinical evaluation
by masking the early symptoms and signs of ACS,
especially pain out of proportion to injury in other-
wise awake and alert patients,15 16 and delay the
diagnosis of ACS17–27 with potentially devastating
consequences.15 16 However, controversy arises
given that RA techniques are among the most effi-
cacious and opioid-­sparing analgesic strategies to
treat post-­ traumatic and/or postoperative ortho-
pedic pain. Furthermore, there are reports in the
literature wherein ACS was appropriately diag-
nosed and successfully managed in the setting of a
single-­injection nerve block or continuous catheter-­
based perineural local anesthetic infusion.28–35
Finally, the likelihood of ACS in the setting of most
elective orthopedic and trauma surgeries is actually
very low. Indeed, much of the available literature
regarding the role of RA for analgesia in the devel-
opment of ACS is limited both in quality and quan-
tity, thereby making any causal association between
the use of RA and the development of ACS a precar-
ious one.
PURPOSE
In an effort to identify scenarios whereby anesthe-
siologists and orthopedic surgeons should avoid or
cautiously consider the use of RA for anesthesia
and/or analgesia, this special article will review the
etiology and address the most common trauma and
elective orthopedic procedures in adults with a view
towards assessing the risk of ACS for each. Proce-
dures will be organized into orthopedic trauma
and elective surgical procedures according to esti-
mated risk of ACS, from greatest to least, based on
our collective clinical experience and expertise in
the fields of orthopedic trauma surgery, elective
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Figure 1  (A) Mid-­shaft tibial fracture. (B) Tibial fracture treated with
intramedullary nail. Reprinted with permission from www.boneschool.
com.
orthopedic surgery, and RA and review of the available litera-
ture. Finally, we will endeavor to make informed and pragmatic
suggestions regarding the suitability of RA for anesthesia and/or
analgesia in the setting of each surgical procedure.
ETIOLOGY OF ACS
Anatomical compartments are closed, non-­elastic muscle regions
that are surrounded by fascia and bone.36 Among the bodily
regions most commonly associated with ACS are the lower leg,
which comprised four such compartments (anterior, lateral,
superficial and posterior),37 the forearm, which has only two
(flexor and extensor) compartments,2 and the foot, which is
described as having nine separate compartments.37 ACS most
commonly affects the legs and feet, but ACS can also affect the
hands, feet, forearms, buttocks and thighs.16
While ACS is primarily encountered in the setting of frac-
tures, it can also occur with vascular and crush injuries.16 38 ACS
secondary to trauma typically develops within the first 48 hours
after injury, but can occur days after the precipitating event.39–41
In the context of surgical fractures, compartment syndrome
may develop before or after the related orthopedic operative
procedure(s). It should also be remembered that ACS can be also
encountered after elective orthopedic surgery, although the risk
in this setting is much lower than emergency trauma.
In the setting of trauma surgery, it is unknown to what extent
the surgical procedure itself either aggravates or mitigates the
development of ACS, which further undermines prognostication
and underscores vigilance. In a study of 273 tibial shaft fractures,
ACS developed in 31 cases (11.4%): 9 cases were diagnosed
preoperatively, 12 cases were diagnosed intraoperatively, and 10
were diagnosed postoperatively and brought back to the oper-
ating room for fasciotomy.41 Interestingly, all 10 patients with
ACS diagnosed postoperatively had surgery performed within
the first 24 hours of admission, suggesting that the initial trauma
led to the development of ACS rather than the surgical proce-
dure itself. Traction and intramedullary nailing have been shown
to result in transient increases in compartmental pressures but it
is unclear whether or not surgical traction and intramedullary
nailing independently increase the risk of ACS.42 In our opinion,
the primary inciting insult for ACS in cases of orthopedic surgical
trauma is likely the initial traumatic injury, and early surgical
stabilization may help mitigate the risk of ACS.
In the setting of elective surgery, ACS is rare and associated
with prolonged surgical procedures, postsurgical bleeding and
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hematoma formation (especially in the setting of anticoagula-
tion), and vascular injury.43
ORTHOPEDIC TRAUMA SURGERY OF THE LOWER LIMB
This section will address the risk of ACS associated with fractures
of the lower limb, starting with those injuries most commonly
associated with ACS. It is important to note that high-­energy
injuries, such as those caused by motor vehicle accidents and fall
from heights, are associated with greater fracture comminution,
hemorrhage, and soft tissue swelling, and are thus more likely to
develop ACS independent of the site of the fracture.
Tibial shaft fractures
Tibial shaft fractures (figure 1) have a reported incidence of
16.9/100 000/year,44 and are recognized as one of the highest
risk injuries for ACS, as they are associated with significant
bleeding and swelling confined within the four small anatomical
compartments of the lower leg. Diaphyseal or mid-­shaft frac-
tures are thought to be most commonly associated with ACS,
although the reported incidence varies widely between 3% and
30%.13 45 46 More severe fracture patterns associated with higher
energy injuries (such as motor vehicle accidents and fall from
heights) are associated with higher risk of ACS.45 However,
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ACS has also been described after low-­energy injuries such as a
fall from standing height and athletic injuries,46 47 especially in
young men,48 and in those treated with intramedullary nails.48
Due to the high risk of ACS with tibial shaft fractures, studies
have evaluated the use of continuous compartment pressure
monitoring, with no evidence that doing so improves outcome
over routine clinical observation.13 49 The latter is likely explained
by the poor correlation between pressure measurements and
clinical symptoms and signs.50 Moreover, the risk of overtreat-
ment, namely unnecessary surgical intervention,51 carries its own
set of potential complications.52 It is important to note that the
literature separately describes the incidence of ACS after injury
and after surgical fixation (with either intramedullary nailing,
external fixation, or plating). While it seems likely that the risk
of ACS may decrease when there is significant delay between
the injury and subsequent surgical fixation, it has been shown
that intramedullary nailing increases compartment pressures.
However, the role of intramedullary nailing in the development
of ACS remains uncertain since fracture stabilization afforded by
early intramedullary nailing does reduce bleeding and swelling,
and may actually lessen the risk of ACS. In a retrospective cohort
study of 772 patients with tibial shaft fractures, 87 (7.73%)
developed ACS, and 64 of these patients required fasciotomy
after surgical fixation, with a mean time from surgical fixation
to fasciotomy of 16 hours.53 It is therefore not surprising that
the use of RA (including epidural anesthesia and peripheral
nerve blocks) has been reported to delay the diagnosis of ACS
in the setting of tibial shaft fractures, sometimes with severe
consequences.17–21
Risk of ACS: High.
Opinion: RA should not be considered in the setting of tibial
shaft fractures.
Tibial plateau fractures
Tibial plateau fractures have an incidence of 10.3/100 000/year,54
and there are many reports of ACS affecting one or more of the
four compartments of the lower leg after intra-­articular tibial
plateau fractures (figure 2).9 As the severity of the tibial plateau
fracture increases due to increased bleeding and swelling (partic-
ularly in the setting of high-­ energy, bicondylar tibial plateau
Dwyer T, et al. Reg Anesth Pain Med 2021;46:1091–1099. doi:10.1136/rapm-2021-102735

Figure 2  (A) Comminuted bicondylar tibial plateau fracture. (B) Tibial
plateau fracture treated with medial and lateral plating. Reprinted with
permission from www.boneschool.com.
fractures), so too does the risk of ACS.55 56 Similar to tibial shaft
fractures, the reported rate of ACS in plateau fractures varies
widely between 1.7% (11/661)45 and 12% (39/326).55 However,
the rate of ACS has been reported to be as high as 17% (25/143)
in high-­energy bicondylar fractures,55 and 53% (9/17) in fracture
dislocations of the medial tibial plateau.57 It is important to note
that severe tibial plateau fractures are often treated by delayed
fixation, most commonly in conjunction with external fixation,
to allow for swelling to resolve, which may reduce the risk of
developing ACS following surgery.56
Risk of ACS: Moderate to high.
Opinion: RA should not be considered in the setting of high-­
energy tibial plateau fractures. For low-­energy unicondylar frac-
tures, the use of RA may be considered with caution and only
after risk-­benefit discussion with the attending surgeon, the care
team and the patient.
Fractures of the foot
ACS affecting one or more of the foot’s nine separate compart-
ments has been described following high-­ energy fractures
(figure 3),58 and can lead to significant disability, including claw
toes, stiffness, motor weakness, and other fixed deformities.59
While calcaneal fractures (10.2/100 000/year) and Lisfranc frac-
ture dislocations of the foot (1.9/100 000/year) are relatively
uncommon,60 ACS is thought to be most prevalent with these
types of higher energy forefoot injuries. Chopart and Lisfranc
fracture dislocations have reported rates of ACS exceeding
20%,61 62 while the rate of ACS after calcaneal fractures is
reported to range from 3.8% to 23%.59 61 63 Calcaneal fractures
(figure 4) complicated by significant comminution are at greater
risk of ACS,63 which may be missed.64 Indeed, the diagnosis of
Figure 3  (A) Intra-­articular displaced fracture of the calcaneum. (B)
Calcaneal fracture treated with lateral plate and screws. Reprinted with
permission from www.boneschool.com.
Dwyer T, et al. Reg Anesth Pain Med 2021;46:1091–1099. doi:10.1136/rapm-2021-102735
Education
Reg Anesth Pain Med: first published as 10.1136/rapm-2021-102735 on 29 June 2021. Downloaded from http://rapm.bmj.com/ on March 3, 2022 at Post Graduate Institute of Medical
Figure 4  (A) Ankle fracture with distal fibular fracture and talar shift.
(B) Ankle fracture treated with fibular plating and syndesmotic screw.
Reprinted with permission from www.boneschool.com.
ACS in the setting of severe foot fractures is difficult, as both the
injury and ACS are associated with significant levels of pain and
swelling in the foot. Persistent pain despite cast immobilization,
pain with passive motion, and sensory changes are important to
identify ACS of the foot, and compartment pressure measure-
Education & Research. Protected by copyright.
ments may be especially helpful to confirm the diagnosis.37 59 65
Risk of ACS: Moderate to high.
Opinion: RA may be considered in most cases, with the excep-
tion of high-­energy injuries such as fracture dislocations, and
calcaneal fractures treated acutely, which can continue to swell
postoperatively.
Tibial plafond fractures
Tibial plafond fractures are thought to represent only 5%–7%
of all tibial fractures,66 and the risk of ACS in the setting of
these distal intra-­articular tibial fractures (figure 5) is thought
to be somewhat lower than for other tibial fractures,45 with
reported rates of 7/326 (2%)55 and 9/342 (2.6%)45 in larger case
series. While the reasons for this reduced rate of occurrence are
unclear, tibial plafond fractures remain high-­energy injuries with
significant associated swelling, and the risk of ACS must not be
discounted. Tibial plafond fractures are typically treated with
delayed surgical fixation, which may reduce the risk of devel-
oping ACS following surgery.
Figure 5  (A) Tibial plafond fracture, with distal tibial fracture
extending into ankle joint. (B) Tibial plafond fracture treated with open
reduction and internal fixation (ORIF) ankle joint and minimally invasive
plating. Reprinted with permission from www.boneschool.com.
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Figure 6  (A) Mid-­shaft femoral fracture. (B) Femoral fracture treated
with intramedullary nail. Reprinted with permission from www.
boneschool.com.
Risk of ACS: Moderate.
Opinion: RA may be considered with caution and only after
risk-­benefit discussion with the attending surgeon, the care team
and the patient.
Femoral shaft fractures
Thigh compartment syndrome is relatively uncommon and
typically associated with blunt trauma to the thigh resulting in
femoral fracture (figure 6),67 vascular injury,68–70 or blunt thigh
trauma in the setting of anticoagulants.71 ACS following femoral
fracture (10/100 000/year)72 can be especially difficult to diag-
nose, as femoral fractures are associated with significant pain and
swelling, identical to the presentation of ACS. For this reason,
ACS in the setting of femoral fractures is associated with delay to
fasciotomy and increased complications,69 71 including persistent
neurological and other functional deficits.67 73 Our review of the
literature uncovered one case report of a femoral nerve block
used prior to intramedullary nailing of a femoral fracture, where
the RA was possibly associated with a delay in diagnosis.22
Risk of ACS: Moderate.
Figure 7  (A) Displaced intertrochanteric neck of femur fracture. (B)
Neck of femur fracture treated with dynamic hip screw. Reprinted with
permission from www.boneschool.com.
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Opinion: RA may be considered with caution and only after
risk-­benefit discussion with the attending surgeon, the care team
and the patient.
Ankle fractures
Ankle fractures (figure 4) are extremely common (179/100
000/year)74 (figure 4), and displaced fractures typically require
surgery, frequently in the ambulatory setting. Fortunately,
compartment syndrome of the leg75 76 and foot77 78 is rarely
described following these injuries, including postoperatively,77
with limited numbers of case reports in the literature.
Risk of ACS: Low.
Opinion: RA may be considered in nearly all cases, with the
possible exception of high-­energy injuries.
Hip fractures
Every year, hundreds of thousands of hip fractures (figure 7)
in the elderly are treated with surgical fixation or replacement
(957/1 000 000/year for women and 414/100 000/year for
men).79 Compartment syndrome is rare, although there have
been reports of ACS in the contralateral leg after lengthy surgical
procedures, due to prolonged position of the well leg in a leg
holder.80
Education & Research. Protected by copyright.
Risk of ACS: Extremely low.
Opinion: RA may be considered in all cases.
ORTHOPEDIC TRAUMA SURGERY OF THE UPPER LIMB
This section will address the risk of ACS associated with frac-
tures of the upper limb, beginning with those injuries believed
to have the highest risk. Again, it is important to note that high-­
energy injuries (motor vehicle accidents, falls from height) have
a greater risk of ACS, independent of the site of the fracture.
Mid-shaft forearm fractures
Fractures of the radius and ulna, excluding wrist fractures, have
an incidence of 64/100 000/year.81 Mid-­shaft fractures of the
radius and/or ulna (figure 8) can be associated with ACS of the
two anatomical compartments of the forearm.82 Higher energy
and more complex fractures of the forearm are more likely to
result in ACS of the forearm,83 as are dual bone fractures84;
however, ACS can also occur secondary to low-­energy mech-
anisms such as a fall from standing height.84 A retrospective
review of the National Trauma Data Bank in the USA, including
301 351 forearm fractures, estimated the incidence of ACS in
the context of single or dual forearm bone fractures to be 1.2%
(3672/301 351).85 In a series of 151 dual forearm fractures, 23
(15%) underwent fasciotomy, suggesting that dual bone frac-
tures of the forearm place the patient at higher risk of ACS.83
From the literature available, it would seem that the majority of
ACS cases occur prior to surgery; the effect of surgical fixation
on the development of postoperative ACS is unclear.
Risk of ACS: Moderate to high.
Opinion: RA should not be considered in the setting of dual
bone forearm fractures and high-­energy single bone fractures.
For low-­energy single bone forearm fractures, RA may be consid-
ered with caution and only after risk-­benefit discussion with the
attending surgeon, the care team and the patient.
Distal radius fractures
Fractures of the wrist (distal radius and ulna) are the most
common fractures of the upper limb, with an incidence of
72/100 000/year.81 ACS of the forearm typically presents within
the first 3 days after distal radius fracture (figure 9), especially
Dwyer T, et al. Reg Anesth Pain Med 2021;46:1091–1099. doi:10.1136/rapm-2021-102735

Figure 8  (A) Dual bone forearm fracture. (B) Dual bone forearm
fracture treated with plating of the radius and ulna. Reprinted with
permission from www.boneschool.com.
following a high-­energy mechanism and with severe fracture
patterns.40 In a series of 6395 fractures of the distal radius, the
overall incidence of ACS of the forearm was 0.25%, but higher
in patients under the age of 35 (1.4%).82 The risk is known to
be higher in patients with ipsilateral elbow injuries, likely due
to higher energy injury.86 The overall incidence of developing
ACS after surgery for distal radius fractures is relatively low
(0.1%, 2/1955), but has been described as a complication of the
surgery,87 and can occur in the setting of delayed procedures.23 28
Risk of ACS: Low to moderate.
Opinion: May consider the use of RA in most cases, with the
exception of younger patients with high-­energy injuries and/
or severe fracture patterns, particularly in the setting of acute
fixation.
Figure 9  (A) Fracture of the distal radius. (B) Fracture of the distal
radius treated with plate. Reprinted with permission from www.
boneschool.com.
Dwyer T, et al. Reg Anesth Pain Med 2021;46:1091–1099. doi:10.1136/rapm-2021-102735
Education
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Figure 10  (A) Elbow dislocation. (B) Elbow dislocation treated with
plating of coronoid fracture and lateral collateral ligament repair.
Reprinted with permission from www.boneschool.com.
Fractures and dislocations of the elbow
Elbow dislocations (figure 10) are relatively uncommon, with
an incidence of 6.1/100 000/year.88 Fortunately, ACS of the
forearm following dislocation and fracture dislocation of the
elbow is thought to be relatively rare event.82
Risk of ACS: Low.
Opinion: May consider the use of RA in most cases, with the
exception of high-­energy injuries associated with forearm and
Education & Research. Protected by copyright.
distal radius fractures, as described above.
Fractures of the proximal humerus, humerus shaft, and distal
humerus
Proximal humerus fractures have a reported incidence of 60/100
000/year.89 ACS in the setting of fractures of the humeral shaft
(figure 11A), proximal humerus (figure 11B,C), and distal
humerus are rare entities, possibly because the fascia of the
upper arm is thought to be more compliant than the compart-
ments of the forearm, and therefore not strong enough to limit
swelling. The fascia of the upper arm also communicates with
the shoulder girdle, significantly expanding the volume of fluid
that can be accommodated.90
Risk of ACS: Low.
Opinion: May consider the use of RA in all cases.
ORTHOPEDIC ELECTIVE SURGERY OF THE LOWER LIMB
Osteotomies about the knee
High tibial osteotomies (figure 12) and distal femoral osteot-
omies are indicated infrequently for osteoarthritis in young
people or in conjunction with meniscal transplant or osteo-
chondral allograft for bone and cartilage defects of the knee.
These are very invasive procedures, associated with reports of
serious complications including vascular injury (2/115, 1.7%)
and consequent ACS (1/115, 0.9%).91
Risk of ACS: Moderate.
Figure 11  (A) Mid-­shaft humerus fracture. (B) Completely displaced
surgical neck of humeral fracture. (C) Surgical neck of humerus fracture
treated with plating. Reprinted with permission from www.boneschool.
com.
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Figure 12  Knee X-­ray following high tibial osteotomy. Reprinted with
permission from www.boneschool.com.
Opinion: RA may be considered with caution and only after
risk-­benefit discussion with the attending surgeon, the care team
and the patient. Providers should be aware of risk of vascular
injury and compartment syndrome postosteotomy.
Knee arthroscopy, anterior cruciate ligament reconstruction
and other ligament reconstruction about the knee
ACS following knee arthroscopy and anterior cruciate ligament
reconstruction (figure 13) is extremely rare, and thought to stem
from extravasation of the fluid used during arthroscopy into the
dependent compartments of the leg, by way of capsular defects.92
In the immediate postoperative period, the arthroscopy fluid will
resorb over time, and fasciotomy is rarely required.93 However,
ACS has also been described following vascular injury,94 and as a
result of bleeding complications.92 Some patients require multiple
elective ligament reconstruction procedures as a consequence of
prior traumatic knee dislocation, which is a high-­energy injury
often associated with vascular injury, and is associated with a
relatively high (2.7%) risk of ACS.95
Risk of ACS: Low.
Figure 13  (A) X-­ray of the knee following anterior cruciate
ligament (ACL) reconstruction. (B) Arthroscopic image following ACL
reconstruction. Reprinted with permission from www.boneschool.com.
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Figure 14  (A) Positioning for hip arthroscopy. (B) Portals for hip
arthroscopy. Reprinted with permission from www.boneschool.com.
Recommendation: RA may be considered in all cases, with
the possible exception of acute surgical management of knee
dislocation.
Foot and ankle surgery
Reports of ACS after ankle arthroscopy96 97 and other elec-
tive foot and ankle procedures are rare,98 possibly due to the
controlled setting of elective surgery, careful hemostasis control,
and the release of fascial compartments during the surgical
approach. However, there does seem to be an association with
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revision surgery and extensive deformity correction,26 99 prob-
ably due to the extensive dissection, invasive nature, and higher
propensity for bleeding and swelling.
Risk of ACS: Low.
Opinion: RA may be considered in all cases, with the possible
exception of extensive deformity correction.
Hip arthroscopy
Similar to knee arthroscopy, there are isolated reports of intra-­
abdominal fluid extravasation and abdominal ACS after hip
arthroscopy (figure 14), in conjunction with psoas tendon
release.100 101 Abdominal ACS is a life-­ threatening condition,
characterized by abdominal pain and distention, difficulty venti-
lating patients, hypothermia, reduced urine output, hypotension,
and potential cardiac arrest.100–102 It is unlikely that standard RA
techniques for hip arthroscopy would mask these symptoms and
signs.
Risk: Very low.
Recommendation: RA may be considered in all cases. Providers
should be aware of the risk of abdominal compartment syndrome
after psoas tenotomy.
Figure 15  (A) Total hip arthroplasty. (B) Total knee arthroplasty.
Reprinted with permission from www.boneschool.com.
Dwyer T, et al. Reg Anesth Pain Med 2021;46:1091–1099. doi:10.1136/rapm-2021-102735
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Reg Anesth Pain Med: first published as 10.1136/rapm-2021-102735 on 29 June 2021. Downloaded from http://rapm.bmj.com/ on March 3, 2022 at Post Graduate Institute of Medical
CONCLUSIONS
While there are no absolute contraindications as regards the use
of RA in settings where ACS is a concern, some fracture patterns,
high-­energy injuries, and surgical procedures do carry a higher
risk and RA should be considered relatively contraindicated. In
these clinical situations, we suggest that RA techniques for anes-
thesia and analgesia should be either avoided or considered with
caution only after a risk-­benefit discussion with the attending
surgeon.

Funding  AN receives research time support from the Fracture Care Research
Endowed Chair, St Michael’s Hospital, Toronto, Ontario, Canada. RB receives
research time support from the Evelyn Bateman Cara Operations Endowed Chair in
Ambulatory Anesthesia and Women’s Health, Women’s College Hospital, and Merit
Award Program, Department of Anesthesia and Pain Medicine, Toronto, Ontario,
Canada.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.

ORCID iD
Richard Brull http://​orcid.​org/​0000-​0002-​7708-​8843

REFERENCES
1 Zibis A, Varitimidis S, Fyllos A, et al. An observational study of complications in

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Figure 16  Total shoulder arthroplasty. Reprinted with permission
from www.boneschool.com.
Total knee and hip arthroplasty
Total hip arthroplasty (THA) (figure 15A) and total knee
arthroplasty (TKA) (figure 15B) are two of the most commonly
performed elective orthopedic procedures; fortunately,
compartment syndrome is extremely rare following these proce-
dures.11 103 104 Among the few case reports and series that have
been published, ACS in the setting of TKA or THA appears
to be associated with surgical misadventure, namely vascular
injury,11 103 105 and/or therapeutic anticoagulation.
Risk of ACS: Very low.
Opinion: RA may be considered in all cases. Providers should
be vigilant in the setting of vascular injury.
ORTHOPEDIC ELECTIVE SURGERY OF THE UPPER LIMB
Shoulder, elbow, and wrist surgery
Open and arthroscopic surgery of the shoulder, including joint
replacement (figure 16), can be associated with hematoma
formation postoperatively, especially in patients on anticoagula-
tion.106 However, ACS is a rare event, likely because the deltoid
compartment is very large, and communicates the compart-
ment of the arm. Similarly, there are no reports of compartment
syndrome in the literature after elbow arthroscopy or arthro-
plasty. There are very few reports of ACS after wrist arthros-
copy, with one study reporting one case in a series of 10 107
procedures (0.001%),107 and only an isolated case report of ACS
of the hand following wrist arthrodesis, again likely due to the
controlled setting of elective surgery.108
Risk of ACS: Very low.
Opinion: RA may be considered in all cases. Providers must be
aware that surgical complexity can vary widely, which may affect
the risk of ACS.
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