Acute compartment syndrome / Reply
The article by McQueen et al1 in the March 2000 issue entitled `Acute compartment syndrome: who is at risk?’ raises a number of important issues.
Many publications have already defined the high-risk patient.2,3 We do not agree that patients suspected of having a compartment syndrome should be monitored, with a fasciotomy if the readings are abnormal. Most surgeons would proceed to fasciotomy if the clinical features dictated, irrespective of pressure recordings.
We also question the authors’ figures concerning rates of fasciotomy for their tibial diaphyseal fractures. A flow chart giving information on how the patients presented, the classification of the fracture, the method of treatment and the timing of diagnosis in relation to treatment would have been of greater benefit to the reader. It is also unclear which compartments were involved in each treatment group. This would be of value if contemplating elective fasciotomy.
The rate of fasciotomy is likely to be higher if relying on pressure studies4 and we doubt that measurements were recorded in all patients. Diagnosis on the basis of muscle bulging or expression of blood at surgery is likewise of dubious value, as any compartment under pressure would behave in this way. No reference is made to the component of time.
Our own experience is that pressure monitoring is rarely performed outside dedicated units, and departments with a device seldom use it to its full potential. Perhaps surgeons are happy with their clinical skills for what is, in reality, a rare condition. Other reasons for not monitoring pressure include lack of experience in positioning sensors, lack of knowledge of whether pressures need to be measured at different sites within each fascial space, and the unknown accuracy of the monitors available.
In the light of increasing litigation, are we now negligent if we do not follow the recommendations from a leading unit? The Journal of Bone and Joint Surgery has previously published work from this centre and must be careful to balance authors’ recommendations with reality, especially if the conclusions do not quite fit the data.
R. ROACH, FRCS Ed
R. PERKINS, FRCS
Princess Royal Hospital
1. McQueen MM, Garston P, Court-Brown CM. Acute compartment syndrome: who is at risk? J Bone Joint Surg (Br] 2000;82-B:200-3.
2. McQueen MM. Compartment syndromes. Management of Open Fractures. Chapter 20, 1996:263-80.
3. Mubarak SJ. A practical approach to compartment syndrome, Part 2. AAOS Instructional Course Lecture 32.
4. Ovre S, Hvaal K, Holm I, et al. Compartment pressure in nailed tibial fractures: a threshold of 30 mmHg for decompression gives 29% fasciotomies. Arch Orthop Trauma Surg 1998;118:29-31.
5. Hargens AR, Mubarak SJ. Current concepts in the pathophysiology, evaluation and diagnosis of compartment syndrome. Hand Clin 1998;14:371-83.
We note with interest your correspondents’ comments. There have been no previous studies of acute compartment syndrome in a defined population to identify the groups of patients who are at most risk of developing the condition.
The recommendation that patients at risk of acute compartment syndrome should undergo tissue pressure monitoring is based on work published four years ago from this unit. At that time we established that the safest threshold for fasciotomy is a differential pressure of 30 mmHg between the diastolic pressure and the tissue pressure.1 In that paper we stated that use of the tissue pressure without reference to the diastolic pressure results in unnecessary fasciotomy. This was confirmed by Ovre et al.2 The rate of fasciotomy in this unit has remained the same despite the introduction of continuous monitoring over 15 years ago.
The advantage of continuous pressure monitoring is that the diagnosis of acute compartment syndrome is made at a mean of 16 hours earlier than occurs when the surgeon relies on clinical findings.3 This results in a significant reduction in the disabling complications of the neglected acute compartment syndrome. Perhaps surgeons should not be happy with their clinical skills for diagnosing a condition which, with an incidence of around 4%, cannot be considered rare. Lack of experience should not be cited as a reason for not using a technique with proven benefits.
The comments about litigation are timely. One of the commonest causes of claims of negligence against orthopaedic surgeons is neglect of an acute compartment syndrome. We recommend continuous monitoring because we feel that the medical rather than the legal profession should be driving advances in the management of patients.
M. M. McQUEEN, MD, FRCS Ed (Orth)
The Lothian University Hospitals NHS Trust
I. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures: the pressure threshold for decompression. J Bone Joint Surg (Br] 1996;78-B:99-104.
2, Ovre S, Hvaal K, Holm I, et al. Compartment pressure in nailed tibial fractures: a threshold of 30 mmHg for decompression gives 29% fasciotomies. Arch Orthop Trauma Surg 1998;118:29-31.
3. McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg (Br] 1996;78-B:95-8.
Copyright British Editorial Society of Bone & Joint Surgery Aug 2000
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