Medline ® Abstracts for References 83-85

We made a prospective study of 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. Three patients had acute compartment syndrome (2.6%). In the first 12 hours of monitoring, 53 patients had absolute pressures over 30 mmHg and 30 had pressures over 40 mmHg, with four higher than 50 mmHg. Only one patient had a differential pressure (diastolic minus compartment pressure) of less than 30 mmHg; he had a fasciotomy. In the second 12-hour period 28 patients had absolute pressures over 30 mmHg and seven over 40 mmHg. Only two had differential pressures of less than 30 mmHg; they had fasciotomies. None of our 116 patients had any sequelae of the compartment syndrome at their latest review at least six months after injury. A threshold for decompression of 30 mmHg would have indicated that 50 patients (43%) would have required fasciotomy, and at a 40 mmHg threshold 27 (23%) would have been considered for an unnecessary fasciotomy. In our series, the use of a differential pressure of 30 mmHg as a threshold for fasciotomy led to no missed cases of acute compartment syndrome. We recommended that decompression should be performed if the differential pressure level drops to under 30 mmHg.

BACKGROUND: Although the importance of monitoring differential compartment pressures (Delta P) after tibial fractures has been established, many surgeons continue to use intramuscular pressures in diagnosing compartment syndrome, despite the limitations of this strategy. The cited reason for this is concern over leaving high intramuscular pressures untreated.

METHODS: One hundred one patients with tibial fractures with satisfactory Delta P were studied. Forty-one patients had elevated intramuscular pressures of over 30 mm Hg for more than 6 hours continuously. These patients were compared with a control group of 60 patients who had pressures of less than 30 mm Hg throughout. Outcome was measured prospectively in terms of muscular power and return to function over the year after injury.

RESULTS: No significant differences were found.

CONCLUSION: Provided Delta P remains satisfactory, patients with elevated intramuscular pressures after tibial fracture do not have a greater incidence ofcomplications than those with low pressures. These patients can therefore be observed safely.

During the past few years we have monitored tissue pressure in patients treated with intramedullary nailing of tibial shaft fractures. A value of 30 mmHg has been used as the threshold for fasciotomy. The purpose of this study was to evaluate this practice. Sixty-three patients were included in the series. Forty-three fractures were closed, 18 grade I (Gustilo) and two grade II. Tissue pressure measurements were performed in 43 patients. Eighteen legs were treated with decompressive fasciotomy, three on clinical findings alone, and 15 after measurement of a pressure higher than 30 mmHg. This gives a fasciotomy rate of 29%. At follow-up two patients were dead. All fractures were healed, and there were no major complications such as deep infection, extensive muscle necrosis, paresis or short-foot syndrome. Three fasciotomized patients had significantly reduced muscle strength compared with the contralateral leg.