SLR - April 2017 - Alissa Kuizinas
Clinical and Functional Outcomes of Acute Lower-Extremity Compartment Syndrome at a Major Trauma Hospital
Reference: Lollo L, Grabinsky A. Clinical and Functional Outcomes of Acute Lower-Extremity Compartment Syndrome at a Major Trauma Hospital. Int J Crit Illn Inj Sci. 2016 Jul-Sep; 6(3):133–142.
Scientific Literature Review
Reviewed By: Alissa Kuizinas, DPM
Residency Program: Hoboken University Medical Center, Hoboken NJ
Podiatric Relevance: Compartment syndrome is a condition that commonly affects the lower extremity and is therefore of particular relevance to the foot and ankle surgeon. While compartment syndrome may be frequently encountered in large trauma centers, it is still possible with a wide variety of etiologies, including lower-extremity fracture, peripheral vascular disease, necrotizing fasciitis and rhabdomyolysis and therefore must be readily detected and treated by all foot and ankle surgeons. This study addresses the functional and clinical outcomes for patients treated for lower-extremity compartment syndrome and provides insight into the disease progression and prognosis.
Methods: This is a retrospective chart analysis of all patients diagnosed with compartment syndrome requiring decompression fasciotomy admitted to a single hospital during a five-year period. A total of 108 patients who underwent fasciotomy were included. The data analyzed included injury severity score, fracture types, pain scores, hours to fasciotomy, intracompartmental pressure measurements and serum creatine kinase levels. Outcome measures were based on lower-extremity neurologic examination, pain scores, orthopaedic complications and employment status at 30 days and 12 months after surgery.
Results: Nontraumatic compartment syndrome was diagnosed in 15.3 percent of patients, with causes including necrotizing fasciitis, peripheral vascular disease, rhabdomyolysis, iatrogenic and rupture of a Baker cyst. Isolated tibia fractures comprised 41.3 percent of the patients, and multiple lower-extremity fractures comprised 18.4 percent. Intracompartmental measurements were recorded in 15.3 percent of patients, with ranges of 39 to 100 mmHg for the lateral compartment, 31 to 140 mmHg in the anterior compartment, 33 to 100 mmHg in the posterior compartment and 16 to 140 mmHg in the deep posterior compartment. Clinical follow-up data showed numbness of the superficial peroneal nerve distribution in 20.5 percent and dropfoot in 18.2 percent of patients. Osteomyelitis developed in 10.2 percent, and heterotopic ossification requiring operative resection occurred in 4.5 percent. At long-term follow-up, 10.2 percent of patients reported moderate lower-extremity pain, and 69.2 percent had returned to work.
Conclusion: This study identified the main causes of diagnosed compartment syndrome and their outcomes based on the severity of injury, time to fasciotomy and associated risk factors. They found that the escalation of pain and patient-reported changes in sensation were more reliable for diagnosis than intracompartmental pressures as they had wide variability in the ranges of pressures measured. The authors suggest that a difference between the diastolic blood pressure and the intracompartmental pressure of less than 30 mmHg is a superior diagnostic tool than absolute pressure. The authors also determined that time to recognition of compartment syndrome and fasciotomy is an important predictor of functional outcome. They found that nerve damage most frequently affects the superficial peroneal nerve causing numbness of the dorsal foot, while injury to the deep peroneal nerve leads to foot drop. The results showed that there was increased severity of nerve damage and greater likelihood for foot drop with delays in fasciotomy. This study highlights the importance of prompt recognition and treatment of compartment syndrome and proves that patient outcomes are improved with early fasciotomy. It also reveals the need for more standardized diagnostic tools and algorithms to detect and treat compartment syndrome as its progression can lead to loss of function, contractures and chronic pain.