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Li W, Zeng Q, Li Y, Chen Y, Bal L, Zhuang Q. Treatment of bilateral Posterior Tibial Compartment Syndrome using a Novel Surgical Approach: A Case Report of the Posterior Approach. Orthop Rev (Pavia) 2024; 16:116374. [PMID: 38666189 PMCID: PMC11043026 DOI: 10.52965/001c.116374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Osteofascial compartment syndrome is a serious surgical emergency that requires prompt diagnosis and treatment. It presents a challenge for surgeons due to its high disability rate and difficult management. Early fasciotomy decompression is crucial in preventing severe complications. Classic fasciotomy approaches for tibial osteofascial compartment syndrome include double-incision and single-incision techniques.This paper presents a case of a 24-year-old female with bilateral tibial posterior compartment syndrome resulting from prolonged squatting after alcohol intoxication, which is a relatively rare mechanism. We employed an innovative posterior approach to manage the patient with tibial posterior compartment syndrome. Ultimately, we successfully preserved the patient's legs and achieved a good functional recovery.The paper reported a rare case with bilateral posterior tibial compartment syndrome resulting from squatting for 10 hours after alcohol intoxication. The patient achieved favorable outcomes in lower limb function following treatment with a new fasciotomy approach, the posterior approach.The new approach for treating posterior tibial compartment syndrome can serve as a valuable reference for surgeons.
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Affiliation(s)
- Wei Li
- Department of orthopedic, No.2 people's hospital of Fuyang city, Yingzhou district, Fuyang city, Anhui province, 23600,China
| | - Qingliang Zeng
- Department of orthopedic, No.2 people's hospital of Fuyang city, Yingzhou district, Fuyang city, Anhui province, 23600,China
| | - Yang Li
- Department of orthopedic, No.2 people's hospital of Fuyang city, Yingzhou district, Fuyang city, Anhui province, 23600,China
| | - Yong Chen
- Department of orthopedic, No.2 people's hospital of Fuyang city, Yingzhou district, Fuyang city, Anhui province, 23600,China
| | - Liang Bal
- Department of orthopedic, No.2 people's hospital of Fuyang city, Yingzhou district, Fuyang city, Anhui province, 23600,China
| | - Quankui Zhuang
- Department of orthopedic, No.2 people's hospital of Fuyang city, Yingzhou district, Fuyang city, Anhui province, 23600,China
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Giotis D, Panagiotopoulos V, Plakoutsis S, Vardakas D, Konstantinidis C. Delayed Presentation of Acute Compartment Syndrome After Isolated Closed Fibular Shaft Fracture: A Case Report. Cureus 2024; 16:e55850. [PMID: 38590458 PMCID: PMC11001258 DOI: 10.7759/cureus.55850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 04/10/2024] Open
Abstract
Post-traumatic compartment syndrome in the lower extremity has been commonly associated with fractures of the tibia. Only in rare cases, this critical condition might be related to isolated fibular fractures. We present a rare case of delayed onset of acute compartment syndrome after a solitary fracture of the fibula. A 40-year-old man with a history of coagulation disorders due to hepatic cirrhosis was admitted to a neighboring hospital after a car accident with left-sided fractures to ribs 9 and 10 and a transverse fracture in the mid-shaft of the left fibula. He was discharged from the hospital five days later with a posterior long leg splint and anticoagulant therapy. However, three days after discharge, he was seen in the emergency department of our hospital with severe pain and extensive swelling in the left leg. Weak posterior tibial and dorsalis pedis pulse in the right foot were detected. Moreover, sensory disturbances were found in the tibia and foot. Passive hallux dorsiflexion and plantar flexion were causing acute intense pain. A triplex ultrasound was negative for deep vein thrombosis. Apart from the clinical findings, the diagnosis of compartment syndrome was confirmed after evaluating intracompartment pressure measurements. The patient was taken emergently to the operating room for four-compartment fasciotomies. A large intramuscular hematoma was evacuated. Skin closure was accomplished in two stages within two weeks. Six weeks postoperatively, there was no sign of compartment syndrome sequelae and the patient was free of symptoms without any neurovascular deficiency in the operated limb and walked without crutches. Ten weeks later, he returned to his pre-injury daily activities. Although the majority of compartment syndrome cases are reported after high-energy trauma, patients with both coagulation disturbances and anticoagulation treatment are at higher risk of developing compartment syndrome secondary to simple fracture patterns.
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Affiliation(s)
- Dimitrios Giotis
- Orthopaedic Department, General Hospital of Ioannina "G. Hatzikosta", Ioannina, GRC
| | | | - Sotiris Plakoutsis
- Orthopaedic Department, General Hospital of Ioannina "G. Hatzikosta", Ioannina, GRC
| | - Dimitrios Vardakas
- Orthopaedic Department, General Hospital of Ioannina "G. Hatzikosta", Ioannina, GRC
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Micicoi L, Gonzalez JF, Gauci MO, Chabrand P, Machado A, Bronsard N, Micicoi G. Acute compartment syndrome of the lower limbs: Fasciotomy or dermofasciotomy? A cadaver study of compartment pressures. Orthop Traumatol Surg Res 2024; 110:103736. [PMID: 37890523 DOI: 10.1016/j.otsr.2023.103736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Acute compartment syndrome (ACS) of the lower limbs is a function-threatening event usually managed by extended dermofasciotomy. Closure of the skin may be delayed, creating a risk of complications when there is an underlying fracture. Early treatment at the pre-ACS stage might allow isolated fasciotomy with no skin incision. The primary objective of this study was to compare intracompartmental pressure (ICP) changes after fasciotomy and after dermofasciotomy. The secondary objectives were to evaluate potential associations linking the starting ICP to achievement of an ICP below the physiological cut-off of 10mm Hg and to determine whether the ICP changes after fasciotomy and dermofasciotomy varied across muscle compartments. HYPOTHESIS Fasciotomy with no skin incision may not provide a sufficient ICP decrease, depending on the initial ICP value. MATERIAL AND METHODS A previously validated model of cadaver ACS of the lower limbs was used. Saline was injected gradually to raise the ICP to>15mmHg (ICP15), >30mmHg (ICP30), and >50mmHg (ICP50). We studied 70 leg compartments (anterior, lateral, and superficial posterior) in 13 cadavers (mean age, 89.1±4.6years). ICP was monitored continuously. Percutaneous, minimally invasive fasciotomy consisting in one to three 1-cm incisions was performed in each compartment. ICP was measured before and after fasciotomy then after subsequent skin incision. The objective was to decrease the ICP below 10mmHg after fasciotomy or dermofasciotomy. RESULTS Overall, mean ICP was 37.8±19.1mmHg after the injection of 184.0±133.01mL of saline. In the ICP15 group, the mean ICP of 16.1mmHg fell to 1.4mmHg after fasciotomy (ΔF=14.7) and 0.3mmHg after dermofasciotomy (ΔDF=1.1). Corresponding values in the ICP30 group were 33.9mmHg, 4.7mmHg (ΔF=29.2), and 1.2mmHg (ΔDF=3.5); and in the ICP50 group, 63.7mmHg, 17.0mmHg (ΔF=46.7), and 1.2mmHg (ΔDF=15.8). Thus, in the group with initial pressures >50mmHg, the ICP decrease was greater after both procedures, but fasciotomy alone nonetheless failed to achieve physiological values (<10mmHg). The pressure changes were not significantly associated with the compartment involved (anterior, lateral, or superficial posterior) (p<0.05). CONCLUSION Under the conditions of this study, higher baseline ICPs were associated with larger ICP drops after fasciotomy and dermofasciotomy. Nevertheless, when the baseline ICP exceeded 50mmHg, fasciotomy alone failed to decrease the ICP below 10mmHg. Adding a skin incision achieved this goal. LEVEL OF EVIDENCE IV, experimental study.
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Affiliation(s)
- Lolita Micicoi
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | - Jean-François Gonzalez
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | - Marc-Olivier Gauci
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | | | - Axel Machado
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | - Nicolas Bronsard
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France
| | - Grégoire Micicoi
- IULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, 06000 Nice, France; Unité de Recherche Clinique Côte d'Azur (UR2CA), CHU de Nice, Université Côte d'Azur (UCA), Nice, France.
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Akgun E, Emet A, Sibar K, Çatma FM, Kocyigit IA, Şahin A, Imat E, Adiguzel IF, Fırat A. Risk Factors for Surgical Site Infections Following Fasciotomy in Patients With Acute Compartment Syndrome: A Study on the February 2023 Kahramanmaraş Earthquake. Cureus 2023; 15:e46880. [PMID: 37841991 PMCID: PMC10568196 DOI: 10.7759/cureus.46880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 10/17/2023] Open
Abstract
INTRODUCTION Surgical site infections (SSIs) developing after fasciotomy are difficult to treat, costly, and an important source of mortality and morbidity. This study aimed to determine the risk factors affecting the development of SSI in patients who underwent fasciotomy with the diagnosis of acute compartment syndrome (ACS) within 72 hours after two consecutive earthquakes of 7.7 and 7.6 magnitude that occurred in Kahramanmaraş on February 6, 2023. METHOD A total of 116 patients were retrospectively analyzed. Patients were divided into two groups: those who developed SSI and those who did not. In this study, variables such as basic demographic characteristics, time of fasciotomy, center performing fasciotomy, type of wound closure, affected extremity, concomitant renal failure, hyperbaric oxygen (HBO) therapy, blood creatine kinase (CK) level were examined. RESULTS Of 116 patients, 58 (50%) had SSI. It was statistically observed that patients who underwent treatment with vacuum-assisted closure (VAC), those who underwent primary closure with the shoelace method, those who went into renal failure, and those whose fasciotomy was performed in an earthquake zone had a higher incidence of SSI (p<0.001). Blood CK level above 17.839 seemed to be a risk factor according to receiver operating characteristic (ROC) analysis (P<0.01). Age (p=0.193), gender (p=0.125), fasciotomy time (p=0.843), lower extremity (p=0.234), upper extremity (p=0.806), and HBO treatment (p=0.56) were not associated with SSI. Infection was found to be a significant risk factor for amputation (p<0.001). CONCLUSION The use of VAC as a wound closure technique for SSI after fasciotomy in patients who developed ACS due to the earthquake, the presence of renal failure in the patients, and performing fasciotomy in the earthquake zone were independent risk factors. A blood CK level above 17.839 was also determined as a risk factor, but the confidence interval was found to be low.
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Affiliation(s)
- Erkan Akgun
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Abdulsamet Emet
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Kemal Sibar
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Faruk M Çatma
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | | | - Ali Şahin
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | - Emrah Imat
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
| | | | - Ahmet Fırat
- Orthopaedics and Traumatology, Ankara Etlik City Hospital, Ankara, TUR
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Nilsson A, Ibounig T, Lyth J, Alkner B, von Walden F, Fornander L, Rämö L, Schmidt A, Schilcher J. BioFACTS: biomarkers of rhabdomyolysis in the diagnosis of acute compartment syndrome - protocol for a prospective multinational, multicentre study involving patients with tibial fractures. BMJ Open 2022; 12:e059918. [PMID: 35501102 PMCID: PMC9062790 DOI: 10.1136/bmjopen-2021-059918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The ischaemic pain of acute compartment syndrome (ACS) can be difficult to discriminate from the pain linked to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is based on clinical findings and performed at a low level of suspicion. Biomarkers of muscle cell damage may help to identify and monitor patients at risk, similar to current routines for patients with acute myocardial infarction. This study will test the hypothesis that biomarkers of muscle cell damage can predict ACS in patients with tibial fractures. METHODS AND ANALYSIS Patients aged 15-65 years who have suffered a tibial fracture will be included. Plasma (P)-myoglobin and P-creatine phosphokinase will be analysed at 6-hourly intervals after admission to the hospital (for 48 hours) and-if applicable-after surgical fixation or fasciotomy (for 24 hours). In addition, if ACS is suspected at any other point in time, blood samples will be collected at 6-hourly intervals. An independent expert panel will assess the study data and will classify those patients who had undergone fasciotomy into those with ACS and those without ACS. All primary comparisons will be performed between fracture patients with and without ACS. The area under the receiver operator characteristics curves will be used to identify the success of the biomarkers in discriminating between fracture patients who develop ACS and those who do not. Logistic regression analyses will be used to assess the discriminative abilities of the biomarkers to predict ACS corrected for prespecified covariates. ETHICS AND DISSEMINATION The study has been approved by the Regional Ethical Review Boards in Linköping (2017/514-31) and Helsinki/Uusimaa (HUS/2500/2000). The BioFACTS study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology recommendations. TRIAL REGISTRATION NUMBER NCT04674592.
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Affiliation(s)
- Abraham Nilsson
- Department of Orthopaedics and Department of Biomedical and Clinical Sciences, Faculty of Health Science, Linköping University Hospital, Linkoping, Sweden
| | - Thomas Ibounig
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, and, University of Helsinki, Helsinki, Finland
| | - Johan Lyth
- Department of Health Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Björn Alkner
- Department of Orthopaedics, Eksjö, Region Jönköping County and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ferdinand von Walden
- Division of Pediatric Neurology, Department of Women's and Children's health, Karolinska Institutet, Stockholm, Sweden
| | - Lotta Fornander
- Department of Orthopaedics, Norrköping, Östergötland County and Department of Biomedical and Clinical Sciences in Norrköping, Linköping University, Linköping, Sweden
| | - Lasse Rämö
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, and, University of Helsinki, Helsinki, Finland
| | - Andrew Schmidt
- Department of Orthopaedics, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Jörg Schilcher
- Department of Orthopaedics and Department of Biomedical and Clinical Sciences, Faculty of Health Science, Linköping University Hospital, Linkoping, Sweden
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Warren M, Dhillon G, Muscat J, Abdulkarim A. Atraumatic Bilateral Acute Compartment Syndrome of the Lower Legs: A Review of the Literature. Cureus 2021; 13:e20256. [PMID: 35018259 PMCID: PMC8739082 DOI: 10.7759/cureus.20256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 12/18/2022] Open
Abstract
Bilateral acute compartment syndrome of the legs is a very rare presentation that requires emergency surgical intervention. Atraumatic bilateral cases are almost unheard of in medicine. There is currently no link between compartment syndrome and cognitive impairment or mental health. A systematic literature search was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines using the following keywords in multiple databases: compartment syndrome, atraumatic, spontaneous, bilateral, both, lower leg, acute, compartmental pressure, and fasciotomy. Atraumatic, bilateral, acute, and confirmed compartment syndrome cases were included. In total, 33 cases of atraumatic bilateral acute compartment syndrome (ABACS) were identified, of those 72.7% of cases were males. A form of cognitive impairment was found in 66% of cases. The medical history of the cases included substance abuse (nine patients), mental health illness (seven patients), and hypothyroidism (four patients). Within the reports, there was evidence of a misdiagnosis or delayed management in 19 cases (57.6%). Creatinine kinase (CK) was measured in 28 cases with a mean CK of 110,893 IU/L. Compartment pressure measurements were used in only 12 cases. A total of 29 cases were managed with bilateral four-compartment fasciotomy. This review highlights that ABACS is a condition with high rates of misdiagnosis or delay in treatment. Associations found included patients with cognitive impairment on presentation, mental health conditions, substance misuse, and elevated levels of CK. In addition, this review demonstrates that this condition is less rare than previously thought with serious morbidity and mortality.
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Affiliation(s)
- Madeline Warren
- Trauma and Orthopaedics, East and North Hertfordshire NHS Trust, Stevenage, GBR
| | - Govind Dhillon
- Trauma and Orthopaedics, East and North Hertfordshire NHS Trust, Stevenage, GBR
| | - Joseph Muscat
- Trauma and Orthopaedics, East and North Hertfordshire NHS Trust, Stevenage, GBR
| | - Ali Abdulkarim
- Trauma and Orthopaedics, University Hospitals Sussex NHS Foundation Trust, Brighton, GBR
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O'Neill CN, Johnsen PH, Stefanski JT, Toney CB. Acute Compartment Syndrome After Isolated Soleus Tear in an Elderly Recreational Athlete. Geriatr Orthop Surg Rehabil 2021; 12:21514593211036234. [PMID: 34422438 PMCID: PMC8377303 DOI: 10.1177/21514593211036234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/27/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022] Open
Abstract
Case A 62-year-old man without significant medical history (no anticoagulation) presented to the emergency department with intense leg pain following a short track race, during which he felt a pop in his calf. His physical exam was highly concerning for acute compartment syndrome (ACS) despite the lack of a typical mechanism or fracture. Compartment pressures were measured and found to be significantly elevated. He underwent compartment releases revealing a medial soleus tear with 400-500 cc hematoma. Conclusion The case presents a patient with ACS after a soleus muscle tear. Prompt recognition and fasciotomy led to a good clinical outcome. Physicians should recognize that not only gastrocnemius tears can lead to compartment syndrome.
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Affiliation(s)
- Conor N O'Neill
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Parker H Johnsen
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
| | - James T Stefanski
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Clarence Brian Toney
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Nathanson MH, Harrop-Griffiths W, Aldington DJ, Forward D, Mannion S, Kinnear-Mellor RGM, Miller KL, Ratnayake B, Wiles MD, Wolmarans MR. Regional analgesia for lower leg trauma and the risk of acute compartment syndrome: Guideline from the Association of Anaesthetists. Anaesthesia 2021; 76:1518-1525. [PMID: 34096035 PMCID: PMC9292897 DOI: 10.1111/anae.15504] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.
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Affiliation(s)
- M H Nathanson
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, President, Association of Anaesthetists (Co-Chair), Nottingham, UK
| | - W Harrop-Griffiths
- Imperial College, Vice President, Royal College of Anaesthetists (Co-Chair), London, UK
| | - D J Aldington
- Hampshire Hospitals NHS Trust, British Pain Society, Hampshire, UK
| | - D Forward
- Department of Trauma and Orthopaedic Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Mannion
- Department of Anaesthesiology, South Infirmary Victoria University Hospital, Irish Standing Committee, Association of Anaesthetists, Cork, Ireland
| | - R G M Kinnear-Mellor
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Surgeon Commander, Royal Navy; Chair, Defence Medical Services Military Pain Special Interest Group, Nottingham, UK
| | - K L Miller
- Department of Paediatric Anaesthesia, Birmingham Women's and Children's NHS Foundation Trust, Trainee Committee, Association of Anaesthetists, Birmingham, UK
| | - B Ratnayake
- Department of Anaesthesia, Kingston Hospital NHS Trust, Immediate Past President, British Society of Orthopaedic Anaesthetists, Immediate Past President, British Society of Orthopaedic Anaesthetists, Kingston-upon-Thames, UK
| | - M D Wiles
- Department of Anaesthesia and Operating Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M R Wolmarans
- Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Past-President, Regional Anaesthesia UK (RA-UK), Norwich, UK
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Klima M. Institutional differences in management of compartment syndrome at academic and community-based trauma centers: A survey of Orthopaedic Trauma Association (OTA) members. OTA Int 2020; 3:e090. [PMID: 33937713 PMCID: PMC8078146 DOI: 10.1097/oi9.0000000000000090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/13/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to compare management of compartment syndrome at academic and community trauma centers and to identify any institutional variables that influence the number of adverse events reported to the hospital's peer review process. DESIGN Web-based survey. SETTING N/A. PARTICIPANTS Orthopedic Trauma Association (OTA) members. METHODS A link to a 9-item web-based questionnaire was sent to members of the OTA. RESULTS Two hundred twenty-four (21%) of 1031 OTA members completed the survey. Respondents indicated that residents were primarily responsible for checking compartments at academic trauma centers (91%), while community trauma centers reported higher utilization rates of ortho attendings (81%), trauma attendings (26%), and nurses (27%). Seventy-five percent of respondents at academic trauma centers relied on intra-compartmental pressure monitoring to make the diagnosis in intubated/obtunded patients as opposed to just 56% of respondents at community centers. Seventy percent of all respondents utilizing prophylactic fasciotomies practiced at community trauma centers. Forty-four percent indicated that they had submitted cases involving management of compartment syndrome to their hospital peer review process. While most submitted only 1 or 2 cases (75% of positive replies), 5% had submitted 5 or more cases for peer review. Use of a pressure monitor and orthopaedic surgeons performing all fasciotomies were associated with a lower number of cases submitted to peer review (P < .02 and P < .04, respectively). CONCLUSION Academic and community trauma centers differ in their utilization of in-house staff for early assessment, in the diagnostic modalities employed in obtunded patients, and in their threshold for fasciotomy. Adverse events are regularly reported for peer review at both academic and community trauma centers. As there is great variability between institutions in terms of clinical practice as demonstrated by the responses to this survey, it is recommended that institutions devise their own written protocol based on the resources they have available to reduce adverse events. LEVEL OF EVIDENCE Therapeutic Level V.
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Saiz AM, Wellman AC, Stwalley D, Wolinsky P, Miller AN. The Incidence and Risk Factors Associated With the Need for Fasciotomy in Tibia and Forearm Fractures: An Analysis of the National Trauma Data Bank. J Orthop Trauma 2020; 34:e154-e158. [PMID: 31738240 PMCID: PMC7991978 DOI: 10.1097/bot.0000000000001702] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aims of this study were to analyze a large national trauma database to determine the incidence of, risk factors for, and outcomes after a fasciotomy of the lower leg or forearm after fracture. METHODS Data from the National Trauma Data Bank for the years 2004-2016 were analyzed, and we identified 301,351 patients with forearm fractures and 369,237 patients with tibial fractures. Risk factors, length of stay (LOS), and mortality were assessed to determine associations with an injury that required a fasciotomy. RESULTS A total of 1.22% of the forearm fractures and 3.79% of the tibial fractures had a fasciotomy. Patients with a fasciotomy were more likely to have invasive procedures (P < 0.0001); have injuries resulting from machinery, motor vehicle collisions, and firearms (P < 0.0001); and smoke, use drugs, and/or alcohol (P < 0.05) compared with patients who did not undergo fasciotomies. Fasciotomy procedures were associated with longer LOS and higher mortality rate (P < 0.05). CONCLUSIONS The incidence of a fasciotomy is less than 5% in tibia or forearm fractures. Patients who underwent fasciotomy have higher energy injuries, increased alcohol or drug use, higher rates of surgical interventions, and increased LOS. Furthermore, having a fasciotomy is associated with increased mortality rate. When counseling patients and evaluating surgeon/hospital performance, fasciotomies can serve as an indicator and modifier for a more complex trauma pathology. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Augustine M. Saiz
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | | | - Dustin Stwalley
- Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Philip Wolinsky
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Anna N. Miller
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO
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Do Patient-specific or Fracture-specific Factors Predict the Development of Acute Compartment Syndrome After Pediatric Tibial Shaft Fractures? J Pediatr Orthop 2020; 40:e193-e197. [PMID: 31157755 DOI: 10.1097/bpo.0000000000001410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tibial shaft fractures are the most common injuries preceding acute compartment syndrome (ACS), so it is important to understand the incidence of and risk factors for ACS after pediatric tibial shaft fractures. The purposes of this study were to determine the rate at which ACS occurs and if any patient or fracture characteristics are significantly associated with developing ACS. METHODS All patients aged 5 to 17 years treated for a tibial shaft fracture at a level 1 pediatric trauma center, a level 1 adult trauma center, and an outpatient orthopaedic practice between 2008 and 2016 were retrospectively identified. Demographics, mechanisms of injury, and fracture characteristics were collected from the medical records. Radiographs were reviewed by study authors. ACS was diagnosed clinically or by intracompartmental pressure measurement. Univariable analysis was performed using the Fisher exact test for nominal variables and simple logistic regression for continuous variables. Multivariable analysis was performed using stepwise logistic regression. RESULTS Among 515 patients with 517 tibial shaft fractures, 9 patients (1.7%) with 10 (1.9%) fractures developed ACS at a mean age of 15.2 years compared with a mean age of 11 years in patients without ACS (P=0.001). One patient with bilateral tibial fractures developed ACS bilaterally. Age greater than 14 years (P=0.006), higher body mass index (P<0.001), motorcycle or motor vehicle accidents (P=0.034), comminuted and segmental tibial shaft fractures (P<0.001), ipsilateral fibular fracture (P=0.002), and associated orthopaedic injuries (P=0.032) were all significantly more common in the ACS group. CONCLUSIONS ACS developed in 1.7% of the patients with tibial shaft fractures in this retrospective study-a rate significantly lower than previously reported. Age greater than 14 years, higher body mass index, motor vehicle or motorcycle accidents, comminuted or segmental fracture pattern, ipsilateral fibular fracture, and associated orthopaedic injuries are all significantly associated with its development. LEVELS OF EVIDENCE Level III-retrospective comparative study.
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Başcı O, Acan AE, Erduran M. Akut kompartman sendromu klinik yaklaşımları: Türkiye'de ortopedi ve travmatoloji doktorlarının uygulamalarının anket ile değerlendirilmesi. EGE TIP DERGISI 2019. [DOI: 10.19161/etd.469758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Nilsson A, Alkner B, Wetterlöv P, Wetterstad S, Palm L, Schilcher J. Low compartment pressure and myoglobin levels in tibial fractures with suspected acute compartment syndrome. BMC Musculoskelet Disord 2019; 20:15. [PMID: 30611244 PMCID: PMC6320587 DOI: 10.1186/s12891-018-2394-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The intense ischemic pain of acute compartment syndrome can be difficult to discriminate from the pain related to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is often only based on clinical findings and performed at a low threshold. Biomarkers of muscle cell damage might help to identify and monitor patients at risk. In patients with fractures, however, markers of muscle cell damage could be elevated because of other reasons associated with the trauma, which would make interpretation difficult. In a review of all patients who underwent emergency fasciotomy in our health care district we aimed to investigate the decision-making process and specifically the use of biomarkers in patients with and without fractures. METHODS In the southeast health care region of Sweden 79 patients (60 men) with fractures (median age 26 years) and 42 patients (34 men) without associated fractures (median age 44 years) were treated with emergency fasciotomy of the lower leg between 2007 and 2016. Differences in clinical findings, p-myoglobin and p-creatine phosphokinase as well as pressure measurements were investigated. RESULTS P-myoglobin was analyzed preoperatively in 20% of all cases and p-creatine phosphokinase in 8%. Preoperative levels of p-myoglobin were lower in patients with fractures (median 1065 μg/L, range 200-3700 μg/L) compared with those without fractures (median 7450 μg/L, range 29-31,000 μg/L), p < 0.05. Preoperative intracompartmental pressure was lower in the fracture group (median 45 mmHg, range 25-90 mmHg) compared with those without fractures (median 83 mmHg, range 18-130 mmHg), p < 0.05. CONCLUSIONS Biomarkers are seldom used in the context of acute fasciotomy of the lower leg. Contrary to our expectations, preoperative levels of p-myoglobin and intracompartmental pressures were lower in fracture patients. These findings support differences in the underlying pathomechanism between the groups and indicate that biomarkers of muscle cell necrosis might play a more important role in the diagnosis of acute compartment syndrome than previously thought.
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Affiliation(s)
- Abraham Nilsson
- Department of Orthopedics and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Björn Alkner
- Department of Orthopedics, Regional Hospital Eksjö, Region Jönköping County and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Patrick Wetterlöv
- Department of Orthopedics, Regional Hospital Eksjö, Region Jönköping County and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | | | - Lars Palm
- Department of Orthopedics and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- Department of Orthopedics and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
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Zhang D, Tarabochia M, Janssen SJ, Ring D, Chen N. Acute compartment syndrome in patients undergoing fasciotomy of the forearm and the leg. INTERNATIONAL ORTHOPAEDICS 2018; 43:1465-1472. [DOI: 10.1007/s00264-018-4060-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 07/12/2018] [Indexed: 11/29/2022]
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Shuler MS, Roskosky M, Kinsey T, Glaser D, Reisman W, Ogburn C, Yeoman C, Wanderman NR, Freedman B. Continual near-infrared spectroscopy monitoring in the injured lower limb and acute compartment syndrome: an FDA-IDE trial. Bone Joint J 2018; 100-B:787-797. [PMID: 29855235 DOI: 10.1302/0301-620x.100b6.bjj-2017-0736.r3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS). Patients and Methods NIRS sensors were placed on 86 patients with, and 23 without (controls), severe leg injury. NIRS values were recorded for up to 48 hours. Longitudinal data were analyzed using summary and graphical methods, bivariate comparisons, and multivariable multilevel modelling. Results Mean NIRS values in the anterior, lateral, superficial posterior, and deep posterior compartments were between 72% and 78% in injured legs, between 69% and 72% in uninjured legs, and between 71% and 73% in bilaterally uninjured legs. In patients without ACS, the values were typically > 3% higher in injured compartments. All seven limbs with ACS had at least one compartment where NIRS values were 3% or more below a reference uninjured control compartment. Missing data were encountered in many instances. Conclusion NIRS oximetry might be used to aid the assessment and management of patients with ACS. Sustained hyperaemia is consistent with the absence of ACS in injured legs. Loss of the hyperaemic differential warrants heightened surveillance. NIRS values in at least one injured compartment(s) were > 3% below the uninjured contralateral compartment(s) in all seven patients with ACS. Additional interventional studies are required to validate the use of NIRS for ACS monitoring. Cite this article: Bone Joint J 2018;100-B:787-97.
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Affiliation(s)
- M S Shuler
- Athens Orthopedic Clinic, Athens, Georgia, USA
| | - M Roskosky
- Johns Hopkins University, Baltimore, Maryland, USA and The Geneva Foundation, Tacoma, Washington, USA
| | - T Kinsey
- Athens Orthopedic Clinic, Athens, Georgia, USA
| | - D Glaser
- Glaser Consulting, San Diego, California, USA
| | - W Reisman
- Grady Memorial Hospital; Emory University School of Medicine, Athens, Georgia, USA
| | - C Ogburn
- Athens Orthopedic Clinic, Athens, Georgia, USA
| | - C Yeoman
- The Geneva Foundation, Tacoma, Washington, USA
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Lor KKH, Yeoh NCS, Wong KP, Wee ATH. Raised compartment pressures are frequently observed with tibial shaft fractures despite the absence of compartment syndrome: A prospective cohort study. J Orthop Surg (Hong Kong) 2018; 25:2309499017717362. [PMID: 28664769 DOI: 10.1177/2309499017717362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To measure the intracompartmental pressures surrounding tibial fractures not exhibiting any clinical evidence of compartment syndrome. Our hypothesis was that pressures often exceed the recommended threshold of fasciotomy despite the absence of compartment syndrome, and hence diagnosis based on pressure measurements alone is unreliable. METHODS Thirteen consecutive patients with closed tibial shaft fractures without clinical suspicion of compartment syndrome, and who were planned for intramedullary nailing, were prospectively enrolled. Compartment pressures ( P) in all four compartments of the affected leg were measured at the start of surgery and immediately after tibial reaming, and differential pressures (delta P) were calculated based on the diastolic blood pressure prior to induction of anaesthesia. RESULTS No patients required reoperation in the post-operative period, as a result of an undiagnosed compartment syndrome. Using commonly quoted threshold pressure criteria, 62% (using P > 30 mmHg) and 23% of patients (using delta P < 30 mmHg) have been incorrectly diagnosed with compartment syndrome. CONCLUSIONS We conclude that raised compartment pressures are frequently seen in patients with tibial shaft fractures; but in most cases, it does not equate to the presence of compartment syndrome. Diagnosis of compartment syndrome based on intracompartmental pressure measurements alone may result in unnecessary fasciotomies in a sizeable number of patients. Compartment syndrome remains a clinical diagnosis, and one which always needs to be considered when managing tibial fractures.
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Affiliation(s)
- Kelvin Kah Ho Lor
- 1 Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
| | | | - Khai Phang Wong
- 1 Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
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O’Connor JV. Penetrating extremity arterial injury. TRAUMA-ENGLAND 2017. [DOI: 10.1177/1460408617715489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- James V O’Connor
- University of Maryland School of Medicine, Baltimore, MD, USA
- Thoracic and Vascular Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Hake ME, Etscheidt J, Chadayammuri VP, Kirsch JM, Mauffrey C. Age and dressing type as independent predictors of post-operative infection in patients with acute compartment syndrome of the lower leg. INTERNATIONAL ORTHOPAEDICS 2017; 41:2591-2596. [DOI: 10.1007/s00264-017-3576-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/03/2017] [Indexed: 11/30/2022]
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Abstract
Acute compartment syndrome is a well-known complication of tibial fractures, yet it remains difficult to diagnose and the only effective treatment is surgical fasciotomy. Delayed fasciotomy is the most important factor contributing to poor outcomes, and as a result, treatment is biased towards performing early fasciotomy. Current diagnosis of ACS is based on clinical findings and intramuscular pressure (IMP) measurement, and is targeted at identifying safe thresholds for when fasciotomy can be avoided. Since clinical findings are variable and difficult to quantify, measurement of IMP - ideally continuously - is the cornerstone of surgical decision - making. Numerous investigators are searching for less invasive and more direct measurements of tissue ischemia, including measurement of oxygenation, biomarkers, and even neurologic monitoring. This article provides a brief but thorough review of the current state of the art in compartment syndrome diagnosis and treatment.
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Affiliation(s)
- Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin County Medical Center, University of Minnesota, 701 Park Ave. South, Mailcode G2, Minneapolis, MN, USA.
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Dubina AG, Paryavi E, Manson TT, Allmon C, O'Toole RV. Surgical site infection in tibial plateau fractures with ipsilateral compartment syndrome. Injury 2017; 48:495-500. [PMID: 27914662 DOI: 10.1016/j.injury.2016.10.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 10/13/2016] [Accepted: 10/17/2016] [Indexed: 02/02/2023]
Abstract
AIM The aim of this study was to investigate the effects of compartment syndrome and timing of fasciotomy wound closure on surgical site infection (SSI) after surgical fixation of tibial plateau fractures. Our primary hypothesis was that SSI rate is increased for fractures with compartment syndrome versus those without, even accounting for confounders associated with infection. Our secondary hypothesis was that infection rates are unrelated to timing of fasciotomy closure or fixation. MATERIALS AND METHODS We conducted a retrospective cohort study of operative tibial plateau fractures with ipsilateral compartment syndrome (n=71) treated with fasciotomy at our level I trauma center from 2003 through 2011. A control group consisted of 602 patients with 625 operatively treated tibial plateau fractures without diagnosis of compartment syndrome. The primary outcome measure was deep SSI after ORIF. RESULTS Fractures with compartment syndrome had a higher rate of SSI (25% versus 8%, p<0.001). The difference remained significant in our multivariate model (odds ratio, 7.27; 95% confidence interval, 3.8-13.9). Delay in timing of fasciotomy closure was associated with a 7% increase per day in odds of infection (95% confidence interval, 0.2-13; p<0.05). CONCLUSIONS Tibial plateau fractures with ipsilateral compartment syndrome have a significant increase in rates of SSI compared with those without compartment syndrome (p<0.001). Delays in fasciotomy wound closure were also associated with increased odds of SSI (p<0.05).
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Affiliation(s)
- Andrew G Dubina
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ebrahim Paryavi
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theodore T Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher Allmon
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
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Anders M, Mutty C, Cornwall A. Geographic variation in fasciotomy during operative management of tibia fractures. J Orthop 2015; 13:225-9. [PMID: 27408482 DOI: 10.1016/j.jor.2015.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/10/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Diagnosis and treatment of acute or impending compartment syndrome (ACS) remains a clinical challenge. ACS is a clinical diagnosis, and may be associated with variation in its definition, as well as individual threshold for fasciotomy. We examined regional and state variation in rates of lower extremity fasciotomy associated with operatively managed tibia fractures. METHODS A total of 313,344 surgically treated tibia fractures were identified via Current Procedural Terminology (CPT) codes using PearlDiver, a private-payer medical record database. Data from the PearlDiver database was compared to the National Trauma Data Bank trauma registry data to corroborate calculated fasciotomy rates. RESULTS The aggregate United States fasciotomy rate derived from PearlDiver was 2.57%. State fasciotomy rates were wide-ranging (0.03%-11.86%) with an average state rate of 2.22% (n = 47, SD = 2.27). CONCLUSIONS There was significant state-to-state variation in the use of fasciotomy during operative management of tibial fractures. Various factors may have contributed to the observed difference of state fasciotomy rates. LEVEL OF EVIDENCE This is a Level III epidemiological study retrospectively comparing geographic rates of fasciotomy during operative management of tibia fractures.
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Affiliation(s)
- Mark Anders
- State University of New York at Buffalo, Dept. of Orthopaedics, Erie County Medical Center, Buffalo, NY 14215, United States
| | - Christopher Mutty
- State University of New York at Buffalo, Dept. of Orthopaedics, Erie County Medical Center, Buffalo, NY 14215, United States
| | - Allison Cornwall
- State University of New York at Buffalo, Dept. of Orthopaedics, Erie County Medical Center, Buffalo, NY 14215, United States
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Risk factors for acute compartment syndrome of the leg associated with tibial diaphyseal fractures in adults. J Orthop Traumatol 2014; 16:185-92. [PMID: 25543232 PMCID: PMC4559534 DOI: 10.1007/s10195-014-0330-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 11/25/2014] [Indexed: 01/08/2023] Open
Abstract
Background We sought to examine the occurrence of acute compartment syndrome (ACS) in the cohort of patients with tibial diaphyseal fractures and to detect associated risk factors that could predict this occurrence. Materials and methods A total of 1,125 patients with tibial diaphyseal fractures that were treated in our centre were included into this retrospective cohort study. All patients were treated with surgical fixation. Among them some were complicated by ACS of the leg. Age, gender, year and mechanism of injury, injury severity score (ISS), fracture characteristics and classifications and the type of fixation, as well as ACS characteristics in affected patients were studied. Results Of the cohort of patients 772 (69 %) were male (mean age 39.60 ± 15.97 years) and the rest were women (mean age 45.08 ± 19.04 years). ACS of the leg occurred in 87 (7.73 %) of all tibial diaphyseal fractures. The mean age of those patients that developed ACS (33.08 ± 12.8) was significantly lower than those who did not develop it (42.01 ± 17.3, P < 0.001). No significant difference in incidence of ACS was found in open versus closed fractures, between anatomic sites and following IM nailing (P = 0.67). Increasing pain was the most common symptom in 71 % of cases with ACS. Conclusions We found that younger patients are definitely at a significantly higher risk of ACS following acute tibial diaphyseal fractures. Male gender, open fracture and IM nailing were not risk factors for ACS of the leg associated with tibial diaphyseal fractures in adults. Level of evidence Level IV.
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Abstract
BACKGROUND Acute compartment syndrome is a rare but serious consequence of traumatic leg injury. Near-infrared spectroscopy (NIRS) is able to measure oxygenation to a depth of 2 cm to 3 cm below the skin, raising concerns over the ability of NIRS to accurately determine oxygenation of injured leg compartments in the presence of swelling and in the obese. The purpose of this study was to measure the thickness of the subcutaneous tissue overlying the posterior muscle compartment in subjects with tibia fractures to determine if it might compromise rSO₂ measurement in the muscle. METHODS Data were analyzed on 50 patients with severe leg injuries. Distance from the skin to the fascia in the superficial posterior compartment of both legs was measured on each patient using a portable ultrasound device. RESULTS Subject age ranged from 18 years to 65 years (mean, 39 years), with 43 male and 7 female patients. The mean (SD) subcutaneous adipose tissue thickness (ATT) was 6.98 (3.17) mm for the injured leg and 7.06 (3.37) mm for the uninjured leg, and the mean body mass index for the group was 27.08 kg/m. No significant correlation was found between the ATT of the injured or uninjured legs and body mass index. Mean comparison testing revealed no difference in ATT between the injured and uninjured legs (null hypothesis: equal means, p > 0.05). Of the 50 subjects analyzed, no subject had a subcutaneous depth of more than 2 cm on the injured or uninjured leg. CONCLUSION These data suggest that, within this traumatically injured population, symptoms associated with leg injury (such as swelling and edema) do not significantly affect the distance from the skin to the fascia. It is also notable that subcutaneous depth beyond the 2-cm mark (validated in previous studies) is a rare occurrence in this population. These results further support the use of continuous NIRS monitoring for diagnosis of acute compartment syndrome. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Fasciotomy Wound Management and Closure—Updated. Tech Orthop 2014. [DOI: 10.1097/bto.0000000000000099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Do one-time intracompartmental pressure measurements have a high false-positive rate in diagnosing compartment syndrome? J Trauma Acute Care Surg 2014; 76:479-83. [DOI: 10.1097/ta.0b013e3182aaa63e] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Extremity compartment syndrome and fasciotomy: a literature review. Eur J Trauma Emerg Surg 2013; 39:561-7. [DOI: 10.1007/s00068-013-0329-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/07/2013] [Indexed: 10/26/2022]
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Abstract
Acute compartment syndrome remains a challenging problem for orthopedic surgeons because its diagnosis is not always straightforward and it has a high risk of associated limb morbidity if left undiagnosed or untreated. Failure to diagnose and treat acute compartment syndrome is one of the most common causes of successful medical liability claims. The authors review the current literature concerning the diagnosis of acute compartment syndrome and discuss new non-invasive technologies that may allow for earlier and more accurate diagnosis of impending acute compartment syndrome.
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Duckworth AD, McQueen MM. Continuous Intracompartmental Pressure Monitoring for Acute Compartment Syndrome. JBJS Essent Surg Tech 2013; 3:e13. [PMID: 30881744 DOI: 10.2106/jbjs.st.m.00023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction We recommended that all patients at risk for acute compartment syndrome undergo continuous intracompartmental pressure monitoring. Step 1 Patient Consent Provide thorough explanations so that the patient can give informed consent to undergo catheter placement and continuous compartment pressure monitoring. Step 2 Position the Patient Perform the procedure with the patient supine, in either the recovery room (post anesthetic care unit) or with adequate assistance on the ward. Step 3 Preparation Have all required items for the slit catheter technique for continuous intracompartmental pressure monitoring with placement under a strict aseptic technique. Step 4 Insert the Catheter At the time of admission to the hospital, insert a slit catheter into the anterior compartment with the catheter tip within 5 cm of the fracture level and 1 to 2 cm lateral to the tibia. Step 5 Attach the Transducer Once the catheter is in position, fill it with normal saline solution and attach it to the transducer and pressure manometry tubing, providing a continuous column of saline solution between the compartment and the transducer. Step 6 Attach the Transducer to the Monitor and Check Reading Once assembly is complete, you must check that the catheter is working properly and providing accurate readings; then measure the patient's blood pressure at the initial and every subsequent reading. Step 7 Continuous Monitoring Perform continuous monitoring for twenty-four hours or until the pressure is consistently dropping and the ΔP is consistently rising, whichever is the longer. Results In our previously published study, we examined 850 patients who underwent continuous intracompartmental pressure monitoring following a fracture of the tibial diaphysis. What to Watch For IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Andrew D Duckworth
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SU, Scotland. E-mail address for A.D. Duckworth:
| | - Margaret M McQueen
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SU, Scotland. E-mail address for A.D. Duckworth:
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McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. J Bone Joint Surg Am 2013; 95:673-7. [PMID: 23595064 DOI: 10.2106/jbjs.k.01731] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of our study was to document the estimated sensitivity and specificity of continuous intracompartmental pressure monitoring for the diagnosis of acute compartment syndrome. METHODS From our prospective trauma database, we identified all patients who had sustained a tibial diaphyseal fracture over a ten-year period. A retrospective analysis of 1184 patients was performed to record and analyze the documented use of continuous intracompartmental pressure monitoring and the use of fasciotomy. A diagnosis of acute compartment syndrome was made if there was escape of muscles at fasciotomy and/or color change in the muscles or muscle necrosis intraoperatively. A diagnosis of acute compartment syndrome was considered incorrect if it was possible to close the fasciotomy wounds primarily at forty-eight hours. The absence of acute compartment syndrome was confirmed by the absence of neurological abnormality or contracture at the time of the latest follow-up. RESULTS Of 979 monitored patients identified, 850 fit the inclusion criteria with a mean age of thirty-eight years (range, twelve to ninety-four years), and 598 (70.4%) were male (p < 0.001). A total of 152 patients (17.9%) underwent fasciotomy for the treatment of acute compartment syndrome: 141 had acute compartment syndrome (true positives), six did not have it (false positives), and five underwent fasciotomy despite having a normal differential pressure reading, with subsequent operative findings consistent with acute compartment syndrome (false negatives). Of the 698 patients (82.1%) who did not undergo fasciotomy, 689 had no evidence of any late sequelae of acute compartment syndrome (true negatives) at a mean follow-up time of fifty-nine weeks. The estimated sensitivity of intracompartmental pressure monitoring for suspected acute compartment syndrome was 94%, with an estimated specificity of 98%, an estimated positive predictive value of 93%, and an estimated negative predictive value of 99%. CONCLUSIONS The estimated sensitivity and specificity of continuous intracompartmental pressure monitoring for the diagnosis of acute compartment syndrome following tibial diaphyseal fracture are high; continuous intracompartmental pressure monitoring should be considered for patients at risk for acute compartment syndrome.
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Affiliation(s)
- Margaret M McQueen
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SU, Scotland
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