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Three Part Question

[In a patient with suspected compartment syndrome of a lower limb] can [clinical signs and symptoms] diagnose [compartment syndrome]

Clinical Scenario

A young man presents to the Emergency Department with a left sided foot drop.He was seen three days ago with blunt injury to his left calf whilst playing football. He was treated as a soft tissue injury and discharged.

On his return he was diagnosed as a case of compartment syndrome.You wonder what is the diagnostic utility of clinical signs and symptoms in the diagnosis of compartment syndrome of the lower limb.

Search Strategy

The literature was searched using following. Medline databases (Ovid interface) 1966 till
April 2010. Embase (Dialogue datastar) 1974 till April 2010. Cochrane Library.
Following search terms were used: [{exp compartment syndrome or compartment syndrome.mp or Volkmann’s Ischemic contracture$.mp} AND {exp leg.mp or exp lower extremity} AND {signs.mp or symptoms.mp} AND {exp.diagnosis}]
A manual search of the bibliographies of retrieved articles and of major orthopaedic
text was also performed. Papers were also identified by cross references of relevant papers.

Search Outcome

368 articles were found out of which 363 were not directly relevant to the study question. This left five papers for analysis as detailed below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Triffit PD et al 1992, LRI (UK) 1992 UK	20 Patients, Isolated closed unilateral tibial shaft fracture treated in plaster cast	Prospective cohort study	Any sign and symptom of CS.	Measured as joint stiffness, contractures or change in cutaneous sensations, 11 patients (55%) an abnormality was found on examination; in three of these there were no symptoms. Statistically(Wilcoxon and chi-squared tests)there was no difference between the two groups(normal and abnormal clinically).	Small study sample. Statistical significance not assessed
M.J.Allen 1985 UK	28 Patients with marked soft tissue trauma to lower limbs	Prospective cohort study	Increase in intracompartmental pressure	18 patients were normal, with regard to both clinical assessment and intracompartmental pressure recording.7 Patients were found by pressure measurement to have a transient compartment syndrome but in only three were supportive clinical features were present.	Small study sample, Statistical methods not described
Ulmer t et al 2002, USA	134 patients with lower limb injuries were included	Systematic review	Sensitivity and specificity of clinical findings in diagnosing compartment syndrome	104 articles were reviewed in there entirety, 04 studies had data to calculate the PPV (Positive predictive value) and NPV (Negative predictive value).The sensitivity, specificity; PPV and NPV for Pain were 0.19, 0.97, 0.14 and 0.98 respectively. Similarly forParaesthesia(0.13,0.98,0.15,0.98)PPS(0.19,0.97,0.14,0.98)Paresis(0.13,0.97,0.11,0.98).	Only Medline search was performed. There were no attempts to search for unpublished literature or to assess publication bias. The quality of study was not assessed. This review includes studies detailed below
M.M.McQueen et al 1990 Scotland, UK	66 Patients intracompartmental pressure monitoring was done while tibial osteotomy	Prospective cohort study	Raised intracompartmental pressure	The overall incidence of acute compartment syndrome was 1.5%. No patient developed any sequale of compartment syndrome.	No gold standard used for CS.
Gibson JJ et al 1986 Uk	20 patients undergoing tibial osteotomy compartment pressure was recorded and related to clinical signs	Prospective cohort study	Increase in compartmental pressure	Out of 20 Patients 8 patients had a rise of ICP more than 45 while 9 had ICP of greater than 30.Only 06 patients showed signs associated with compartment syndrome found only when a pressure greater than 45 mmHg had been present for more than five hours.	Small study sample

Comment(s)

The conclusion from this analysis is that there is paucity of good quality data from which to determine the predictive value of clinical findings for the diagnosis of compartment syndrome. However it appears that clinical findings for the diagnosis are of low sensitivity. This is of concern given the proportion of emergency physicians who feel confident to exclude the diagnosis of compartment syndrome on clinical grounds only. The high index of suspicion is needed when dealing with potential compartment syndromes.

Clinical Bottom Line

Further studies are needed to fully define the discriminatory ability of clinical features for the diagnosis of Compartment syndrome of the lower limb.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. P.D.TRIFFITT Compartment pressures after closed tibial shaft fracture J Bone Joint Surg 1992;74-B:195-8
2. M.J.Allen Intracompartmental pressure monitoring of leg injuries Journal of bone and joint surgery January 1985;53-7
3. Ulmer T The clinical diagnosis of compartment syndrome of the lower leg: Are clinical Journal of orthopaedic trauma vol.16, no 8, 2002.572-577
4. M.M.McQueen Compartment pressures after intramedullary nailing of the tibia J Bone Joint Surg [Br] 1990; 72-B: 395-7 J Bone Joint Surg [Br] 1990; 72-B: 395-7
5. Gibson JJ Weakness of foot dorsiflexion and changes in compartment. J Bone Joint Surg 1986; 62:471-475.