Compartment Syndrome - Current Trends in Scottish Practice

 SMJ 2003 48(3): 82-84

A Vassalos, B Rana, PRN Patterson, P Grigoris

University Department of Orthopaedics, Western Infirmary, Glasgow

Correspondence to:

B Rana, Orthopaedic Registrar, University Department of Orthopaedics, Western Infirmary,  Dumbarton Road, Glasgow G11 6NT.  Email: B.Rana@ukgateway.net

 

Abstract

The results are reported of a postal survey into current trends in the management of compartment syndrome and the use of compartment pressure monitoring (CPM) within Scottish trauma units. 

The majority of consultants in the study felt that all patients, especially the obtunded, with suspected compartment syndrome should be diagnosed using a combination of clinical review and CPM. 73% had CPM devices available representing an increase of 27% compared with previously published UK data. 43% improvised a device using a standard CVP/Arterial-line, transducer and monitor. Marked variation in threshold pressure was noted with the majority recommending perfusion pressure (PP) of diastolic blood pressure (DBP) – intracompartmental pressure (ICP) < 30mmHg for intervention.

We have found no published evidence to suggest that CPM in itself is harmful. Although a marked variation in intervention threshold exists in the literature, we would support a perfusion pressure of <30mmHg as being a safe, familiar and conservative intervention threshold, particularly when used in conjunction with clinical assessment. 

 

Introduction

Compartment syndrome is defined as a group of signs and symptoms that occur when increased tissue pressure, in a limited fascial space, compromises the circulation and function of the tissues within. 

Traditionally the diagnosis of compartment syndrome has relied on clinical suspicion.  Absent or equivocal physical findings can delay diagnosis and treatment making complications more likely.1,2,3  This is particularly true of obtunded patients in whom an impairment of physical or mental status interferes with their ability to respond normally to questions or physical examination.  Obtunded patients include the multiply injured, burn victims, neurologically impaired, infants or young children and substance abusers. 

Direct measurement of intracompartmental pressure can be a valuable adjunct in patients with equivocal findings and may be the only reliable means of confirming compartment syndrome in the obtunded patient.1,2,4,5   A recent review of orthopaedic practice in the UK showed that less than half of the trauma centers surveyed had CPM equipment available.6 With the ongoing debate regarding the indications for CPM and the interventional threshold thereafter we set out to establish current Scottish trends in the management of compartment syndrome, following a review of the literature to date. 

 

Method

A telephone survey of all trauma units in Scotland, as listed in the medical directory, identified 105 practicing orthopaedic trauma consultants.  A four-part tick box questionnaire was sent to each consultant, between March and April 2001 (Table 1).  Completed questionnaires received before August 2001 were included in the results.

 

Results

Case load

In total, 73 completed questionnaires were returned within the allocated time period. The mean number of cases of suspected compartment syndrome presenting to each consultant was 5 (range 1-20).  

Compartment syndrome diagnosis

55% felt that all patients with suspected compartment syndrome should be diagnosed using a combination of clinical review and CPM with the remainder adopting a purely clinical approach.

 

71% recommend hourly clinical appraisal of patients with suspected compartment syndrome (figure 1).

 

In response to the question, ‘How do you assess for raised compartment pressure in unconscious patients or in those who are unable to communicate pain level’, twenty-three of the thirty-three consultants who normally diagnosed compartment syndrome purely on clinical grounds considered the use of CPM.  Seven stated that there was no role for CPM in the diagnosis of compartment syndrome in any patient and three were doubtful towards its benefit.  Therefore somewhat in contrast to traditional views, the majority of consultants in the study would advocate the use of CPM as an adjunct to the clinical assessment of patients with potential compartment syndrome, especially regarding the obtunded patient.

 

Equipment

73% of consultants in the study had CPM devices available for use in their department. However, 25% of this group admitted to not knowing which particular type of equipment they had.

15% used commercially available equipment.

43% improvised a device using a standard CVP/Arterial-line, transducer and monitor. 17% used ‘whitesides method’. 1 A summary of the CPM equipment available in orthopaedic trauma units throughout Scotland is presented in table 2.

27% of consultants in the study had neither commercially available CPM equipment nor the expertise to improvise it. Thirteen of the twenty consultants within this group felt that their practice would benefit from acquiring monitoring equipment. There appears to be an established presence of CPM devices within Scottish orthopaedic departments.  Furthermore the majority of departments without equipment would like to obtain a device.

Interpretation

38% advocated the use of a PP of (DBP – ICP) < 30mmHg as their intervention threshold pressure. 21% used a PP (DBP-ICP) < 35mmHg; 11% used an absolute ICP >30mmHg; 4% used an absolute ICP > 40mmHg. One consultant believed a PP <30mmHg in relation to a persisting upward trend in ICP as an indication for surgery. 25% did not know which intervention threshold pressure to use.  The majority of consultants supported the perfusion pressure proposed by McQueen and Court-Brown of <30mmHg as their intervention threshold (figure 2).

70% advocated continuous/hourly CPM (continuous monitoring implied hourly recordings in the majority of cases assessed). Regular monitoring in this way is empirical for the early diagnosis of compartment syndrome in the asymptomatic or obtunded patient.1,3,4,5  The distributions of frequencies of CPM used are shown in figure 3.

 

Discussion

There is extensive evidence in the literature demonstrating the benefits of CPM, but this practice has failed to achieve universal acceptance.1,3,4,5,6  We have found no published evidence to suggest that CPM in itself is harmful. Our survey indicates that 73% of Scottish trauma consultants reviewed have CPM devices available for use within their departments.  This could be considered to represent an increase of 27% when compared with previously published data regarding UK availability in 1998.6 

In addition, there appears to have been a shift in the type of CPM devices available with the majority of Scottish trauma consultants improvising a device using a standard CVP/A-line, transducer and monitor.  Previously published data on the UK demonstrated an equal distribution between commercially available equipment and improvised devices.6  

Ouellette reviewed the indications for CPM in obtunded patients and there is evidence supporting the use in children.4,7,8,9  Furthermore, the majority reinforced the opinion that hourly clinical assessment and CPM was paramount to the early diagnosis of compartment syndrome in the asymptomatic or obtunded patient.1,4,5,10  Our survey showed that 86% of Scottish orthopaedic trauma consultants advocated the use of CPM in suspected cases of compartment syndrome, when including obtunded patients.

 

The successful use of CPM depends on clear evidence as to the intervention threshold.2 However a marked variation in opinion regarding the intervention threshold when CPM is applied exists within the literature.1,2,3,5,6,11,12  These differences are likely to be due to the wide range of monitoring methods available and whether the model adopted considers variations in systolic blood pressure, commonly associated with the trauma victim.4,5  The use of absolute ICP values for intervention is inconsistent when one considers individual variations in tissue pressure tolerance in relation to age, sex and mode of injury and results in unnecessary fasciotomy.2,5 

McQueen and Court-Brown established that a PP <30mmHg, Whitesides’ recommendation, was the safest threshold for fasciotomy, proposing its routine use in all tibial fractures.1,3,5    The reliability of this threshold was demonstrated in a study of 116 patients with tibial diaphyseal fractures in whom the use of a PP <30mmHg as the intervention threshold led to no missed cases of compartment syndrome.  In total 113 patients were managed conservatively and 3 required fasciotomy. None of the patients had any sequelae of compartment syndrome at 6-month follow up.5  In a separate study of 25 patients they found that the diagnosis of compartment syndrome, using a PP <30mmHg as their intervention threshold, was made at a mean of 16 hrs earlier than when the surgeon relied purely on clinical findings. They observed a significant delay in bone union in fractures in which compartment pressure was not monitored.3   The majority of Scottish trauma consultants evaluated supported a PP <30mmHg as their intervention threshold, which is recommended by McQueen and Court-Brown. However, 25% did not know which intervention threshold pressure to adopt. This figure may be related to the variation expressed in the literature.

 

Mars & Hadley found ICP monitoring to be useful in children with suspected compartment syndrome. They utilized a PP (Mean Arterial Pressure - ICP) of <30mmHg as their intervention threshold. Out of 30 patients, 9 patients required fasciotomy, managing conservatively 5 patients with absolute compartment pressures between 30 and 44mmHg with no demonstrable morbidity. They concluded that absolute pressures were unreliable and other patient factors must be taken into account, particularly their mean arterial pressure.7

 

Janzing et al recently compared the various intervention thresholds recorded within the literature to date.2   95 patients were included in the study with a follow up of at least one year. It was their opinion that there was no intervention threshold currently in use, which has an acceptable combination of sensitivity and specificity for diagnosis of compartment syndrome.  They found that the model proposed by Whitesides (PP<30mmHg) and later validated by McQueen and Court-Brown, had the highest sensitivity but poor specificity. In contrast, clinical evaluation alone had high specificity but low sensitivity. Similarly, the use of CPM in their study resulted in no monitoring related complications.

 

Conclusion.

Our survey indicates that a significant proportion of patients benefit from the use of CPM. We have found no published evidence to suggest that CPM in itself is harmful. As the availability of monitoring equipment is increasing, we would advocate that surgeons familiarise themselves with a recognised technique of compartment pressure assessment. Although a marked variation in intervention threshold exists in the literature, we would support a perfusion pressure of < 30mmHg as being a safe, familiar and conservative intervention threshold, particularly when used in conjunction with clinical assessment. 

 

References

  1. Whitesides TE, Haney TC, Morimoto K Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop1975; 113: 43-51.

  2. HMJ Janzing, PLO Broos. Routine monitoring of compartment pressure in patients with tibial fractures: beware of overtreatment. Injury 2001; 32: pp415 – 421.

  3. McQueen M, Christie J, Court-Brown CM. Acute Compartment Syndrome in Tibial Diaphyseal Fractures. J Bone Joint Surg 1996; 78-B: 95-8.

  4. Ouellette EA. Compartment syndromes in obtunded patients. Hand Clinics 1998;Vol.14 No 3: 431-450.

  5. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. J Bone Joint Surg 1996; 78-B: 99-104.

  6. Williams PR, Russell ID, Mintowt-Czyz WJ. Compartment pressure monitoring-current UK orthopaedic practice. Injury 1998;Vol. 29 No3: 229-232.

  7. Mars M Hadley GP. Raised compartmental pressures in children: a basis for management. Injury 1998;Vol. 29:183-185.

  8. Brogle PJ, Gaffney JT Denton JR. Acute compartment syndrome complicating a distal tibial physeal fracture in a neonate. The American Journ of Orthopaedics 1999:587-589.

  9. Wright R, Reynolds SL, Nachtsheim B. Compartment syndrome secondary to prolonged             intraosseous infusion. Pediatric Emerg Care 1994;Vol 10 No 3: pp157-159.

  10. Mubarak SJ, Owen CA, Hargens AR et al. Acute Compartment Syndromes: Diagnosis and Treatment with the Aid of the Wick Catheter. JBJS 1978;Vol 60-A:pp109-1095.

  11. Heppenstall RB, Sapega AA, Scott R et al. The compartment syndrome. Clin Orthop 1988;226: pp138-155.

  12. Matsen FA III, Compartment Syndromes. New York, Grune & Stratton, 1980.

  13. JGB Maclean, DS Barrett. Rhabdomyolysis: a nelected priority in the early management of severe limb trauma. Injury 1993;Vol. 24/No.3: pp 205-207.

 

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