Pressure Measurement: Surrogate of Ischemia
May 1, 2020
United States trauma surgeons reported that the clinical assessment using the intra-compartmental pressure monitor, should be utilized in the awake patient and continuous monitoring using the slit catheter is recommended in the obtunded or unconscious patient.
The incidence of acute compartment syndrome is documented to be 3.1 per 100,000 population/year. Males are more frequently affected than females (10:1) and the mean age is quoted at just over thirty years, with males younger than females. A delay in the diagnosis of acute compartment syndrome is associated with a potentially devastating outcome for the patient. It is well established that the expedient diagnosis of acute compartment syndrome followed by an urgent fasciotomy and decompression, provides the best outcome for the patient by avoiding irreversible tissue ischemia and necrosis.
Brief Case Description
A key risk factor for acute compartment syndrome is youth, with more than two thirds of cases associated with an underlying fracture. Pain has been noted as the index or key sign associated with acute compartment syndrome. However, clinical assessment alone has been documented to have poor diagnostic performance diagnostic performance characteristics, with the sensitivity quoted in the literature 13-54%. Intra-compartmental pressure monitoring of at risk patients has recently been found to have a high sensitivity (94%) and specificity (98%) when utilizing a slit catheter technique (STIC intra-compartmental slit catheter) and a differential pressure threshold of 30 mmHg for more than two hours. There is now clinical experimental data supporting a differential pressure of greater than 30 mmHg as diagnostic for acute compartment syndrome requiring a fasciotomy. A delay in the diagnosis of acute compartment syndrome can be potentially devastating of the patient.
Intervention and Outcome Summary
Continuous pressure monitoring should be utilized as a diagnostic adjunct in all patients at the risk of developing acute compartment syndrome, with youth the key factor in tibial diaphyseal fractures the most common precipitating injury identified in the literature. Patients and surgeons need to acknowledge that when using compartment pressure monitoring for diagnosing acute compartment syndrome, the risk should inevitably lean towards an unnecessary fasciotomy rather than a missed diagnosis of acute compartment syndrome.
A Guide to Diagnosis and Management
Andrew D. Duckworth, Charles M. Court-Brown, Margaret M. McQueen