Introduction

• Acute compartment syndrome (ACS) arises when elevated pressure within an inextensible osteofascial compartment leads to microvascular compromise, local tissue hypoxia, and ischaemia.
• The guideline applies to all acute extremity trauma, post-surgical interventions, and prolonged hypoperfusion states; chronic exertional compartment syndrome is explicitly excluded.
• Prompt diagnosis and immediate decompression are vital to prevent irreversible neuromuscular necrosis, limb loss, and systemic complications.

Institutional Standards and Training

• All receiving hospitals managing musculoskeletal trauma must ensure staff across the care pathway undergo dedicated training to recognise ACS.
• Standardised clinical observation charts (such as RCN limb observation charts) must be routinely implemented.
• Hospitals must maintain readily accessible capability for objective intracompartmental pressure (ICP) monitoring.
• Clear protocols must be established for patients in whom clinical assessment is non-evaluable or equivocal (e.g., unconscious, sedated, paediatric, or with regional anaesthesia).

Clinical Diagnosis

• Assessment for ACS must be systematically performed and documented in high-risk scenarios, including extremity fractures, crush injuries, after limb surgery, or following protracted operative positioning with hypoperfusion.
• The key early clinical diagnostic features are severe pain out of proportion to the primary injury and exacerbation of pain upon passive stretching of the muscles within the compartment.
• Neurological deficits and distal vascular findings (loss of pulses, altered capillary refill) are late manifestations indicating established tissue ischaemia and should not be relied upon for early diagnosis.

Management and Surgical Decompression

• When ACS is suspected, immediately release all circumferential dressings, splints, or casts down to the skin to alleviate external constriction.
• The extremity should be kept level with the heart to maximise perfusion pressure without elevating venous outflow resistance.
• Emergent surgical decompression via multi-incision dermatofasciotomy is indicated if clinical signs persist or compartment pressure criteria are met.
• All fascial compartments of the affected segment must be completely decompressed under direct vision using generous, unconstrained skin incisions.
• For leg ACS, a two-incision four-compartment fasciotomy (anterolateral and posteromedial incisions) must be executed.
• Muscle viability must be formally inspected across each compartment (assessing colour, contractility, consistency, and bleeding).
• Delayed primary closure, negative pressure wound therapy (NPWT), or split-thickness skin grafting should be planned, with mandatory planned return to theatre within 48 to 72 hours for formal reassessment.