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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.

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

Search Outcome

96 Papers were found of which 4 were relevent.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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
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.
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
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

Comment(s)

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. However, 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. 3 (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.

Clinical 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

1. Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH Acute compartment Syndromes: diagnosis and treatment with aid of the wick catheter J Bone Joint Surg Am. 1978;60:1091-1095.
2. SS Blick, RJ Brumback, A Poka, AR Burgess and NA Ebraheim Compartment Syndrome in Open Tibial Fractures J Bone Joint Surg Am 1986;68:1348-1353
3. Koman LA, Hardaker WT Jr, Goldner JL Wick Catheter in evaluating and treating compartment syndromes. Southern Medical Journal March 1981, Vol 74 Issue 3
4. M. M. MCQUEEN, C. M. COURT-BROWN COMPARTMENT MONITORING IN TIBIAL FRACTURES JBJS Br 1996;78-B:99-104