Anatomic location of penetrating lower-extremity trauma predicts compartment syndrome development

doi:10.1016/j.amjsurg.2008.11.013

The American Journal of Surgery

Volume 197, Issue 3, March 2009, Pages 371-375

https://doi.org/10.1016/j.amjsurg.2008.11.013 Get rights and content

Abstract

Background

Compartment syndrome of the lower extremity can be a difficult diagnosis to make with serious consequences if diagnosis and intervention is delayed. Identifying patients who are more likely to develop this syndrome can help prevent the associated complications. The purpose of this study was to evaluate whether the anatomic location of the penetrating lower-extremity injuries can predict development of compartment syndrome.

Methods

A retrospective chart review was performed of all patients admitted for a minimum of 23 hours to the University of South Alabama trauma center for penetrating lower-extremity trauma during the 8-year period from July 1998 through June 2006. Patients were entered in the study if wound trajectory was confined to the lower extremity between the inguinal ligament and the ankle. Injuries were categorized as above knee (AK) or below knee (BK), and whether the injury was in the proximal or distal half of the extremity segment. Clinical examination or compartmental pressures were used to diagnose BK compartment syndrome.

Results

A total of 321 patients sustained 393 lower-extremity injuries during the study period, of which 255 (65%) were AK and 138 (35%) were BK. Thirty-one (8%) lower extremities developed BK compartment syndrome with 29 (94%) secondary to penetrating injuries of the BK segment. All BK injuries that developed compartment syndrome were located in the proximal half of the BK segment. Eighteen (7%) AK injuries underwent BK 4-compartment fasciotomy, 16 (6%) of which were prophylactic after surgical intervention for AK vascular injury. Two patients (1%) developed postoperative BK compartment syndrome after superficial femoral vein ligation. All AK injuries that underwent fasciotomy sustained vascular injuries requiring surgical intervention. No BK compartment syndromes occurred in any patients with expectantly managed AK or distal BK injuries.

Conclusions

Injuries to the proximal half of the BK segment are the most common cause for the development of compartment syndrome from penetrating injuries of the lower extremity. Development of BK compartment syndrome because of penetrating AK injury is rare without an associated surgically significant vascular injury. Observational admission for compartment syndrome development in patients with penetrating injury to the AK segment or distal BK segment is unnecessary.

Section snippets

Methods

A retrospective chart review was performed of all patients admitted for a minimum of 23 hours to the University of South Alabama trauma center for penetrating lower-extremity trauma during the 8-year period from July 1998 through June 2006. Patients were gleaned from the University of South Alabama's Trauma Registry of the American College of Surgeons. Individual medical records then were reviewed for data extraction. The Investigational Review Board of the University of South Alabama approved

Results

A total of 321 patients sustained a total of 393 lower-extremity injuries during the study period. A total of 255 (65%) were AK penetrating injuries and 138 (35%) were BK penetrating injuries. The average age of patients entered in the study was 30.8 years (range, 14–78 y). A total of 298 (93%) patients were male and 23 (7%) were female. A total of 330 (84%) injuries were secondary to gunshot wounds, 32 (10%) were secondary to stab wounds, and 24 (6%) were the result of shotgun injuries.

Comments

Development of compartment syndrome after penetrating injuries to the lower extremity is a rare occurrence, however, when it does occur and is diagnosed in an untimely fashion, devastating physical disability including loss of limb can occur. Compartment syndrome results from a compromise in capillary perfusion of tissues within the confined space of a fascial compartment. This typically results from increased venous pressure within the compartment. A vicious cycle develops that leads to muscle

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The past 20 years have witnessed major changes in the approach to the severely injured patient. As the principles of damage control surgery have become more common, strategies to stabilize injured patients often involve rapid control of vascular injury. In many cases this can result in vascular ligation as a default method to rapidly address bleeding. As an alternative to ligation, temporary vascular shunts may be used to simply and quickly restore perfusion in the setting of an axial vessel injury. Although shunts are not a novel concept, their use has become more widespread based on clinical experience and data stemming from the most recent wars in Afghanistan and Iraq. In these combat settings, damage control maneuvers (to include shunt use) are often applied to allow safe transport of patients across long distances or between echelons of care. In translation to civilian trauma, shunts have also shown promise as a way to stabilize, resuscitate, and optimize surgical capability within a trauma system. The use of shunts has additional benefit when used to extend the window of limb salvage, particularly in the setting of complex extremity injury patterns and even some truncal injuries. In summary, intraluminal vascular shunts are a useful tool that provides a temporizing option when faced with the “should I ligate or should I repair?” question. Understanding the history of shunts, their technical features and the evidence supporting their use will help surgeons apply this tool more effectively when the scenario arises.
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The past 30 years has witnessed a fundamental change in the approach to the multiply-injured patient. With increasing enthusiasm for the dogma of damage control surgery, surgical strategies to quickly stabilize a severely injured patient have focused on methods of vascular control and on cessation of hemorrhage—the latter often meaning a default to vascular ligation if simple, quick repairs are not feasible. Use of a temporary vascular shunt to expeditiously restore perfusion in the setting of a significant axial vessel injury, however, has now become an accepted alternative to ligation. While vascular shunts are not novel concepts, their use has become greatly encouraged by experience afforded by the wars in Afghanistan and Iraq. Promising outcomes in the management of complex extremity vascular injury have also been echoed in the civilian literature where the necessity of shunt use is driven by the damage control imperative rather than the need to transport patients to a higher level of care. Some surgeons have expanded use of these adjuncts to the management of truncal vascular injuries where ligation often carries significant morbidity and mortality in an already-threatened patient. As such, the intraluminal vascular shunt is a valuable concept that provides surgeons with a much-needed solution to the perpetual dilemma of whether to repair or to ligate a major vascular injury.
Incidence and predictors for the need for fasciotomy after extremity trauma: A 10-year review in a mature level i trauma centre
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Compartment syndrome is a devastating complication after trauma to the extremities. Prompt fasciotomy is essential for avoiding disability and limb loss. The purpose of this study was to determine the incidence and predictors for the need for fasciotomy after extremity trauma.
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During the study period, 288 (2.8%) of a total of 10,315 patients who sustained extremity trauma required a fasciotomy. Despite a stable ISS and extremity AIS over the study period, fasciotomy rates decreased significantly from 3.2% in 1998 to 2.5% in 2002 to 0.7% in 2007 (p < 0.001).
The need for fasciotomy varied widely by mechanism of injury (from 0.9% after motor vehicle accident to 8.6% in GSWs, p < 0.001) and by type of injury (from 2.2% in closed fracture to 41.8% in combined vascular injury, p < 0.001). Patients requiring fasciotomy were predominantly male (90.6% vs. 73.5%, p < 0.001) and had higher ISS (14.5 ± 9.7 vs. 12.8 ± 10.6, p = 0.006). Patients requiring fasciotomy received significantly more units of PRBCs (8.2 ± 13.9 vs. 1.8 ± 5.1, p < 0.001) during their hospital stay. Patients requiring fasciotomy were more likely to sustain open fractures (upper: 8.3% vs. 5.2%, p = 0.031 and lower: 28.5% vs. 11.8%, p < 0.001); joint dislocations (elbow: 25.0% vs. 8.3%, p = 0.005, and knee: 31.2% vs. 6.5%, p < 0.001) and brachial (8.0% vs. 1.1%, p < 0.001), femoral (20.1% vs. 1.1%, p < 0.001) and popliteal vessel injuries (15.3% vs. 0.4%, p < 0.001). A stepwise logistic regression identified the presence of vascular injury, need for PRBC transfusion, male gender, open fracture, elbow or knee dislocation, GSW, ISS ≥ 16 and age < 55 years as independent predictors for the need for fasciotomy.
After extremity trauma, approximately 1% of patients will require a fasciotomy. The need for fasciotomy varied widely by injury mechanism and type reaching 42% in patients who sustained a combined arterial and venous injury. The above risk factors were identified as independent predictors for the need for fasciotomy.
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The Midwest Surgical AssociationAnatomic location of penetrating lower-extremity trauma predicts compartment syndrome development

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Surgery

Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies

World J Surg

Compartment syndrome in both lower legs after prolonged surgery in the lithotomy position

Ned Tijdschr Geneeskd

Acute atraumatic compartment syndrome in the leg

Int Orthop

Gunshot wounds below the popliteal fossa: a contemporary review

Am Surg

Civilian trauma in the 1980s: a 1-year experience with 456 vascular and cardiac injuries

Ann Surg

Advances in the management of acute popliteal vascular blunt injuries

J Trauma

Changing patterns of arterial injuries associated with fractures and dislocations

J Am Coll Surg

The Midwest Surgical Association
Anatomic location of penetrating lower-extremity trauma predicts compartment syndrome development