Diagnosing acute compartment syndrome: are current textbooks misleading?

Abstract

Background: Prompt diagnosis of acute compartment syndrome (ACS) is critical when trying to prevent irreversible limb damage. Pain out of proportion and pain on passive tendon stretching are sufficient clinical indicators of ACS. Primary care physicians may delay in making the diagnosis of ACS because they may rely on the classic “5 P” signs. However, paralysis and pulselessness will not appear until the later stages of ACS, at a time when irreversible damage has occurred. The aim of this study was to evaluate the guidelines for diagnosis of ACS as perceived by graduating medical students and primary care physicians and as published in textbooks. Methods: One hundred and seventeen medical students and primary care physicians were questioned as to the diagnostic criteria of ACS. Eleven medical textbooks were reviewed to evaluate the diagnostic approach to ACS. Results: Of the 117 participants, only 29 (24.8%) answered correctly. Of eleven textbooks, three specifically mentioned the classic “5 P” signs but still provided the correct diagnostic steps, including the essential elements of pain beyond proportion and pain upon passive tendon stretching. Disappointingly, seven textbooks made no mention of the potentially life and limb-threatening diagnosis of ACS, and only one textbook outlined the path to diagnosis of ACS with no mention of the “5 P” signs. Conclusions: The misguided diagnosis according to the “5 P” signs in nonorthopaedic medical textbooks that clinicians in multiple disciplines depend on may result in devastating consequences. Pulselessness, paresthesia, and paralysis are signs that appear too late in the course of the disease to serve as diagnostic signs and are not signs to be waited for, a point to be emphasized in teaching.