Extremity compartment syndrome: What you need to know

ABSTRACT: Acute compartment syndrome of the extremities represents one of the few true orthopedic surgical emergencies, and early surgical fasciotomy is the only effective treatment. Ironically, the classic guidance emphasizing the clinical "6 P's" for establishing the diagnosis (pain, pallor, poikilothermia, pulselessness, paresthesia, paralysis) is inherently misleading, since pain out of proportion, refractory to analgesics, often represents the sole clinical indicator of an evolving acute compartment syndrome. The remaining "5 P" symptoms generally indicate a late or missed compartment syndrome, which is associated with preventable adverse patient outcomes and a risk for nondefensible litigation. The science on this topic is compromised by the absence of a defined diagnosis, which remains predicated by the treatment modality of whether a fasciotomy was performed or not. The current "What you need to know" article was designed to unveil enigmatic myths, misconceptions, and controversies around the conundrum of acute extremity compartment syndrome, based on the current available evidence in the field. Evidence-based recommendations include the recently updated 2025 Clinical Practice Guideline by the American Academy of Orthopaedic Surgeons (AAOS), the American College of Surgeons' TQIP best practice guidelines, and published consensus recommendations from the British Orthopaedic Association and the Association of Anesthetists of Great Britain. The intent of this narrative review is to provide the general surgeon with clinically relevant tips and tricks and to deliver pragmatic decision-making strategies with the ultimate goal of improving patient safety and clinical outcomes.