Elsevier

Injury

Volume 42, Issue 10, October 2011, Pages 1157-1163
Injury

Incidence and predictors for the need for fasciotomy after extremity trauma: A 10-year review in a mature level I trauma centre

https://doi.org/10.1016/j.injury.2010.07.243Get rights and content

Abstract

Background

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.

Methods

All trauma patients sustaining extremity injuries admitted to the LAC + USC Medical Centre during a 10-year period ending in December 2007 were identified. Demographics, clinical data, blood requirements and outcomes were abstracted. Patients who required an extremity fasciotomy were compared with those who did not. Stepwise logistic regression analysis was used to identify independent predictors of the need for fasciotomy.

Results

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.

Conclusion

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.

Section snippets

Background

Compartment syndrome (CS) is an important clinical entity requiring prompt diagnosis and management as delayed treatment is associated with unacceptably high rates of disability and limb loss [11], [13], [14], [15], [16], [18]. Once diagnosed, fasciotomy is necessary to release the pressure within the compartment and prevent ischemic damage to muscles and neurovascular structures. CS is usually diagnosed clinically, however compartment pressure as well as perfusion pressure monitoring has also

Methods

After IRB approval, a retrospective review of the institutional trauma registry at the Los Angeles County + University of Southern California Medical Centre was performed. All trauma patients sustaining extremity injuries admitted to our institution between 1998 and 2007 were identified. The study population was divided into two groups; patients who required a fasciotomy and those who did not.

Patient variables extracted included gender, age, injury mechanism, admission vital signs, Glasgow Coma

Results

During the 10-year study period, 10,315 (30.3%) of a total of 34,002 trauma patients admitted to the LAC + USC Medical Centre sustained extremity trauma. Of those, 288 (2.8%) required a fasciotomy (272 therapeutic and 16 prophylactic) and 10,027 (97.2%) did not (Fig. 1). Fourteen (0.1%) of 23,687 patients who did not sustain extremity trauma also required an extremity fasciotomy due to CS; these patients all had major abdominal vascular injuries. The characteristics of these patients are

Discussion

The early diagnosis of CS is important as treatment delays result not only in an increased risk of complications secondary to limb ischemia but also in a higher mortality [11], [13], [14], [15], [16], [18]. Once diagnosed, prompt fasciotomy is necessary to release the pressure inside the compartment and prevent further damage to muscles and nerves. The diagnosis of CS is primarily clinical, however, compartment pressure as well as perfusion pressure monitoring has also been used as important

Conflict of interest

We have no conflict of interest to disclose.

References (18)

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