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Use of pressure measure alone insufficient to detect compartment syndrome
Soley basing diagnosis on the measure could lead to unnecessary fasciotomy.
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Researchers of a recently presented study caution clinicians that reliance on a one-time, intracompartmental pressure measurement alone to diagnose compartment syndrome might lead to a high rate of false positives.
“Clinicians should be aware that basing their diagnosis on pressure measurements alone would have led to unnecessary surgery in a third of our patient population,” Augusta C. Whitney, MD, of the University of Maryland, said during her presentation at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting.
Methodology
To determine the rate of false positives in the diagnosis of compartment syndrome when clinicians use a one-time pressure measurement alone, Whitney and colleagues prospectively studied 48 patients older than 18 years who sustained tibial shaft fracture. The investigators excluded patients from the study who had ipsilateral tibial plateau or pilon fractures and those who were suspected to have compartment syndrome by the attending physician.
The researchers recorded patients’ diastolic blood pressure preoperatively and in the operating room before the administration of anesthesia. At a single time point after patients received anesthesia, the investigators measured compartment pressures in all four compartments of patients’ legs at the level of the fracture using a commercially available device, Whitney said.
The investigators performed a standardized physical exam postoperatively and at 6-month follow-up to determine whether patients developed compartment syndrome.
No compartment syndrome found
The investigators found that two patients had abnormal motor or sensory examinations at final follow-up. One had an ipsilateral sciatic nerve injury at the time of the tibial shaft fracture and had persistent nerve palsy, and one patient had bilateral motor weakness and known concomitant spine pathology. However, the researchers found no cases of missed compartment syndrome in any of these patients.
Of the patients, 23% had a compartment pressure measurement within 20 mm Hg of diastolic blood pressure. Seventeen patients (35%) showed compartment pressure measurements within 30 mm Hg of their diastolic blood pressures, and 10 patients (21%) surpassed the threshold of 45 mm Hg.
“Of note, we used preoperative diastolic blood pressure to calculate our delta values,” Whitney said. “It has been well described that blood pressure reliably decreases upon induction of anesthesia. We recorded an intraoperative blood pressure value as well, and had we used the intraoperative diastolic pressure values as opposed to the preoperative diastolic blood pressure values, the rate of false positive diagnosis would have been much greater.”
Whitney noted that clinicians should not rely on some compartment pressure values alone, which may lead to a higher rate of diagnosis of compartment syndrome.
“Physical examination is often stated to be the gold standard for the diagnosis of compartment syndrome. However, [for] patients who are intubated, intoxicated or otherwise unable to provide a reliable examination, evidence in emerging that we need to develop more accurate diagnostic testing.” – by Renee Blisard
Reference:
- Whitney AC, O’Toole RV, Sciadini MF, et al. Do intra-compartmental pressure measurements have a high false positive rate in diagnosing compartment syndrome? Paper #611. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.
For more information:
- Augusta C. Whitney, MD, can be reached at the University of Maryland Affiliated Hospitals, 22 S. Greene St., Ste. S11B, Baltimore, MD 21201; 1-800-492-5538; email: awhitney@umoa.umm.edu.
- Disclosure: Whitney has no relevant financial disclosures.