Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis†

Acute compartment syndrome can cause significant disability if not treated early, but the diagnosis is challenging. This systematic review examines whether modern acute pain management techniques contribute to delayed diagnosis. A total of 28 case reports and case series were identified which referred to the influence of analgesic technique on the diagnosis of compartment syndrome, of which 23 discussed epidural analgesia. In 32 of 35 patients, classic signs and symptoms of compartment syndrome were present in the presence of epidural analgesia, including 18 patients with documented breakthrough pain. There were no randomized controlled trials or outcome-based comparative trials available to include in the review. Pain is often described as the cardinal symptom of compartment syndrome, but many authors consider it unreliable. Physical examination is also unreliable for diagnosis. There is no convincing evidence that patient-controlled analgesia opioids or regional analgesia delay the diagnosis of compartment syndrome provided patients are adequately monitored. Regardless of the type of analgesia used, a high index of clinical suspicion, ongoing assessment of patients, and compartment pressure measurement are essential for early diagnosis.