Manual Forearm Palpation in Acute Forearm Compartment Syndrome Is Not Accurate: A Cadaveric Study.

Abstract

Manual compartment palpation is used as a component of the clinical diagnosis of acute compartment syndrome (ACS), particularly in obtunded patients. However, its utility and accuracy in the upper limb are unknown. The purposes of this study were to assess the accuracy of manual compartment palpation of ACS in the forearm in a cadaveric model and to assess the role of clinician experience in this setting. Reproducible, sustained elevation of intracompartmental pressure was established in 8 fresh upper-limb cadaveric specimens. The 3 forearm compartments (volar, dorsal, and mobile wad) were randomized to pressures of 20 and 40 mm Hg (negative controls) and 60 and 80 mm Hg (ACS). This was achieved by using fluid infusion and a pressure monitoring system. Orthopaedic clinicians with varying experience (residents, registrars, and consultants) used palpation to assess forearm compartments with known intracompartmental pressures. The examiners were blinded to the compartment pressures and the other examiners' responses. After the examination, the following 3 questions were answered: (1) Was compartment syndrome present? (2) In which compartment(s) was the pressure elevated? (3) What would be the next management step (fasciotomy or observation)? Manual palpation of compartment pressure had an overall sensitivity of 70%, a specificity of 56%, a positive predictive value of 24%, a negative predictive value of 90%, and a likelihood ratio (LR) of 20.3 (p < 0.001). The sensitivity was similar in detecting ACS in the volar and dorsal compartments (70% and 69%, respectively). The sensitivity and specificity of combined volar and dorsal compartment palpation were 81% and 64% (LR, 16.6; p < 0.001) when performed by residents, 72% and 46% (LR, 4.2; p = 0.040) when performed by registrars, and 58% and 63% (LR, 3.6; p = 0.057) when performed by consultants. All of the compartments that were deemed positive for ACS were recommended for fasciotomy. In our study, manual palpation of compartment pressure had a low accuracy in the diagnosis of ACS of the forearm and was not improved by clinician experience. We recommend against the use of manual palpation of compartment pressure in the diagnosis of forearm ACS in an obtunded patient.