SLR - April 2017 - Rai Kang
Managing Missed Lower-Extremity Compartment Syndrome in the Physiologically Stable Patient: A Systematic Review and Lessons from a Level I Trauma Center
Reference: Glass GE, Staruch RM, Simmons J, Lawton G, Nanchahal J, Jain A, Hettiaratchy SP. Managing Missed Lower-Extremity Compartment Syndrome in the Physiologically Stable Patient: A Systematic Review and Lessons from a Level I Trauma Center. J Trauma Acute Care Surg. 2016 Aug;81(2):380–7.
Scientific Literature Review
Reviewed By: Rai Kang, DPM
Residency Program: Hoboken University Medical Center
Podiatric Relevance: Compartment syndrome is a surgical emergency, and it can be argued that success in managing missed compartment syndrome is prompt diagnosis in all cases. Although rarely reported, missed cases of compartment syndrome cannot be entirely avoided owing to diminished patient consciousness, inadequate fasciotomies, delayed consult, anesthesia or poor clinical judgment. This article offers review of current available literature and the authors' own study from a Level I trauma center in an attempt to define the optimal management of these uncommon cases.
Methods: This is a systematic review of 69 full-text articles (233 screened) searched from Pubmed, EMBASE, MEDLINE, the Cochrane database of systematic reviews and the Cochrane central register of controlled trials. Online trials registers, including ClinicalTrials.gov and the National Research Register, were scrutinized for completed, discontinued and ongoing trials of compartment syndrome. Study quality of the literature was assessed using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach where study design, risks of bias, imprecision, inconsistency and indirectness were accounted to assess quality of evidence. In addition, a retrospective review of a lower-limb trauma database from January 2005 to May 2015 was performed to find all cases of missed compartment syndrome at a Level I trauma center. A delay of 10 hours was considered “missed” for the purpose of study, and the primary outcome measure was the Medical Research Council (MRC) motor score.
Results: The systematic review of literature yielded nine studies with a total of 57 patients and 64 limbs. Delayed decompression resulted in amputation rates from 21 percent with a median delay of 37 hours to 80 percent with a median delay of 48 hours. Out of the 63 limbs, 21 amputations were required, and two subsequent deaths occurred. The remaining one case was managed nonoperatively and resulted in muscle atrophy and ipsilateral foot drop. Retrospective study at a Level I trauma center comprised 10 cases of missed acute lower-limb compartment syndrome with median delay of 36 hours. Six patients were managed operatively where nonviable tissue was debrided along with fasciotomies. Three of the six resulted in amputations and the other three salvaged limbs. Among the salvaged limbs, two underwent ankle fusion due to complete foot drop (MRC 0/5). Four patients were managed nonoperatively, which resulted in two partial foot drop (MRC 3/4) and one resolved foot drop (MRC 4/5).
Conclusion: The authors conclude that, while the evidence is sparse, a nonoperative approach in physiologically stable patients may improve limb salvage and long-term function. Due to the rarity of the cases, it is unlikely that a randomized controlled trial will be established. However, a multicenter prospective study in the future will help determine the optimal treatment approach for these complex cases.