What compartment pressures in closed tibial fractures should we treat to prevent compartment syndrome?
Date First Published:
August 12, 2010
Last Updated:
August 13, 2010
Report by:
Al-Hadithy, SHO Orthopaedics (Barnet and Chase Farm Hospital)
Search checked by:
Shafic Al-Nammari, Barnet and Chase Farm Hospital
Three-Part Question:
[In adults with closed tibial fracture], [what compartment pressure should we treat] [to prevent compartment syndrome].
Clinical Scenario:
A 32 year old man was brought into A&E following a motorcycle accident. He was complaining of pain in his right lower leg. On examination his calf was minimally swollen, soft, neurovascularly in tact, however he was complaining of pain. We suspected a mid-shaft tibia fracture, and this was proven on X-ray.
Given the high risk of compartment syndrome with mid-tibia fracture, compartment pressure monitors were used. The orthopaedic registrar mentioned that 30mmHg was an absolute value to treat compartment syndrome. You are wondering if there is any evidence to support or refute this.
Given the high risk of compartment syndrome with mid-tibia fracture, compartment pressure monitors were used. The orthopaedic registrar mentioned that 30mmHg was an absolute value to treat compartment syndrome. You are wondering if there is any evidence to support or refute this.
Search Strategy:
OVID interface on the world wide web. 1966 – August 2010
((compartment syndrome or compartment pressure) and (monitor or measure or evaluate) and (value or reading or evaluate)).mp.
LIMIT to English AND Randomised Controlled Trial
((compartment syndrome or compartment pressure) and (monitor or measure or evaluate) and (value or reading or evaluate)).mp.
LIMIT to English AND Randomised Controlled Trial
Outcome:
96 Papers were found of which 4 were relevent.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Acute compartment Syndromes: diagnosis and treatment with aid of the wick catheter Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH 1978 | Sixty-five compartments of twenty-seven patients who were clinically suspected of having acute compartment syndromes | Prospective | Indication for fasciotomy | 30mmHg | No measurement of diastolic blood pressure. No mention of signs of compartment syndrome intraoperatively Small Study. No blinding/randomization. |
| No of fasciotomies | 11 patients with 27 compartments decompressed | ||||
| Compartment Syndrome in Open Tibial Fractures SS Blick, RJ Brumback, A Poka, AR Burgess and NA Ebraheim 1986 USA | 180 Patients who had 198 acute open fractures limited to tibial shaft. | Retrospective review. | Indication for fasciotomy | High index of suspicion, degree of soft tissue injury. No definitive compartment pressure found to be of significance for diagnosing compartment syndrome. | No measurement of diastolic blood pressure. |
| No of fasciotomies performed | 16 patients. | ||||
| Wick Catheter in evaluating and treating compartment syndromes. Koman LA, Hardaker WT Jr, Goldner JL 1981 USA | 45 patients with suspected compartment syndrome in limbs. | Prospective study | Indication for fasciotomy | Pressure >30mmHg for >4hrs, Single pressure >40mmHg | No measurement of diastolic blood pressure |
| No. of fasciotomy | 1 | ||||
| COMPARTMENT MONITORING IN TIBIAL FRACTURES M. M. MCQUEEN, C. M. COURT-BROWN 1996 Scotland | 116 patients with tibial diaphyseal fractures, at risk of compartment syndrome. | Prospective Study | Indication for fasiciotomy | Compartment pressure 30mmHg less than diastolic blood pressure. | |
| No of fasicotomies | 1 |
Author Commentary:
There is controversy about which value of compartment pressures to treat. Over the years, there have been varying absolute values of compartment pressures that should be treated. Early studies in 70s and 80s found that absolute values of 30mmHg, indicated the need for a fasciotomy. Other studies also found absolute values of 40mmHg, and 45mmHg were the critical value the caused tissue ischaemia.
tHowever, none of those studies took into account the diastolic values of the varying patients. More recently (1996), McQueen and Court-Brown performed a large (116patient) prospective study of 116 patients with tibial diaphyseal fractures. They found that 53 (45%) of patients had pressures over 30mmHg, 30 (26%) had pressures over 40mmHg and 4 (3.5%) had pressures over 50mmHg.
t3 (2.6%) patients had compartment syndrome. If they had used a threshold for decompression of 30mmHg, nearly 50% of patients would have undergone an unnecessary fasciotomy. They have suggested using a differential pressure of 30mmHg less than the diastolic as an indication for fasciotomy and that there would have been no missed cases of acute compartment syndrome.
tHowever, none of those studies took into account the diastolic values of the varying patients. More recently (1996), McQueen and Court-Brown performed a large (116patient) prospective study of 116 patients with tibial diaphyseal fractures. They found that 53 (45%) of patients had pressures over 30mmHg, 30 (26%) had pressures over 40mmHg and 4 (3.5%) had pressures over 50mmHg.
t3 (2.6%) patients had compartment syndrome. If they had used a threshold for decompression of 30mmHg, nearly 50% of patients would have undergone an unnecessary fasciotomy. They have suggested using a differential pressure of 30mmHg less than the diastolic as an indication for fasciotomy and that there would have been no missed cases of acute compartment syndrome.
Bottom Line:
There is strong evidence showing that absolute pressures should not be used as a guide to treating compartment syndrome. A compartment pressure of 30mmHg less than the diastolic pressure is a more accurate measure,
References:
- Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH. Acute compartment Syndromes: diagnosis and treatment with aid of the wick catheter
- SS Blick, RJ Brumback, A Poka, AR Burgess and NA Ebraheim. Compartment Syndrome in Open Tibial Fractures
- Koman LA, Hardaker WT Jr, Goldner JL. Wick Catheter in evaluating and treating compartment syndromes.
- M. M. MCQUEEN, C. M. COURT-BROWN. COMPARTMENT MONITORING IN TIBIAL FRACTURES