|Year : 2016 | Volume
| Issue : 1 | Page : 10-15
The prevalence and pattern of acute compartment syndrome of the limbs in a private orthopedic and trauma center, Southeast, Nigeria: 8 years retrospective study
Thaddeus Chika Agu1, Mathew Emeka Orjiaku2
1 Department of Surgery, Imo State University, Owerri; Department of Surgery, First Choice Specialist Hospital, Nkpor, Nigeria
2 Department of Surgery, Imo State University Teaching Hospital, Orlu, Nigeria
|Date of Web Publication||8-Dec-2016|
Dr. Thaddeus Chika Agu
Imo State University, Owerri, Nigeria. First Choice Specialist Hospital, Nkpor
Source of Support: None, Conflict of Interest: None
Background: Acute compartment syndrome of the limb is an orthopedic emergency. The leg compartments, usually following fracture of the tibia are most commonly implicated.
Study Design and Setting: This is a retrospective study on the scope of compartment syndrome among patients with limbs traumas who were treated between October 2007 and September 2015 in a private orthopedic and trauma center situated in a highly populated south eastern Nigerian city.
Patients and Methods: The medical records as well as data from the operation register master list of patients with limb injuries were studied. Limb injuries considered significant enough for in-hospital treatments with or without other associated system injuries were included while patients with any form of arterial disease or claudication were excluded.
Results: A total of 1362 patients met the inclusion criteria. Fourteen patients (1.02%) had acute compartment syndrome. The commonest underlying pathology was fracture of the tibia in eight patients (57%). Two patients (14%) were due to tight traditional bone setters' splints and one (7%) was from burns eschar. There was a slight male predominance and young adults in their primes were mostly affected.
Conclusion: Acute compartment syndrome of the limb is not very common. Early clinical diagnoses in the absence of the pressure monitoring equipment is recommended and emergency fasciotomies are necessary to salvage the limbs.
Keywords: Compartment syndrome, fasciotomy, Nigeria, orthopedic emergency, retrospective study
|How to cite this article:|
Agu TC, Orjiaku ME. The prevalence and pattern of acute compartment syndrome of the limbs in a private orthopedic and trauma center, Southeast, Nigeria: 8 years retrospective study. Afr J Trauma 2016;5:10-5
|How to cite this URL:|
Agu TC, Orjiaku ME. The prevalence and pattern of acute compartment syndrome of the limbs in a private orthopedic and trauma center, Southeast, Nigeria: 8 years retrospective study. Afr J Trauma [serial online] 2016 [cited 2017 Dec 16];5:10-5. Available from: http://www.afrjtrauma.com/text.asp?2016/5/1/10/192844
| Introduction|| |
Compartment syndrome in a limb is a rise in the pressure within the osseofascial compartment above the limit that permits normal function of the muscles, nerves, and blood vessels within the compartment. Compartment syndrome could arise in a limb due to three distinct pathological processes. First, the decrease in compartment volume from external compressive factors that compromise the blood flow and decrease the relative distensibility of the compartment such as cast and traditional bonesetters' splint. Second, the increase in the content of the compartment without a corresponding increase in space such as the accumulation of hematoma and inflammatory exudates within a tight osseofascial compartment causing decreased perfusion from within as seen commonly in fracture tibia. Third, the reperfusion syndrome with the release of inflammatory mediators and accumulation of postischemic edema that compromise further blood flow following delayed tourniquet removal. Sometimes, more than one pathological process may be involved in the development of acute compartment syndrome in a limb. For instance, application of tight bonesetters' splint on a fractured tibia with rapidly accumulating hematoma in the leg. The compartment has limited capacity for expansion to accommodate hematoma and inflammatory exudates because of the relative inelasticity of the encasing fascia. This limit varies in individuals and in compartments and when exceeded, the structures within the compartment will develop ischemia. This is recognized early by severe pain that is not in synchronization with the degree of injury and pain that is refractory to analgesics. Furthermore, a passive dorsiflexion of the toes will cause excruciating pain in the calf. These are the early features of acute compartment syndrome necessary for clinical diagnosis.
Available reports in the literature show that compartment syndrome is not common,, but clinicians should be familiar with its presentations, recognize it early and institute emergency treatment to avoid gangrene, and thus a devastating amputation. It has been noted that the most important cause of poor outcome from acute compartment syndrome is delay in diagnosis., Unfortunately, in our environment, there are often delays in seeking contemporary orthopedic consults as many patients would patronize the traditional bonesetters first and because of this, many cases of acute compartment syndrome present late as gangrene,, or at the stage when fasciotomy cannot forestall the late complication of deformity such as Volkmann's ischemic contracture.
A delayed diagnosis of acute compartment syndrome and late fasciotomy could have catastrophic consequences and not only can it lead to loss of limb function or irreversible muscle damage, but also there may be the systemic manifestations of acidosis, hyperkalemia, myoglobinuria, shock, sepsis, and eventual renal failure that may lead to death., Despite the drawbacks in clinical diagnosis, especially in unconscious or sedated patients or in those patients who cannot cooperate with clinical methods or those who have neural problems and so cannot feel pain, clinical assessment is still the diagnostic cornerstone of acute compartment syndrome in the majority of the patients. Compartment pressure measurements and monitoring only become absolutely necessary when there is a suspicion, but the clinical features are equivocal. However, compartment pressure varies in individuals and in a person from time to time, depending on the diastolic blood pressure., The differential pressure between the compartmental and the diastolic pressures becomes critical if this delta P is <30 mmHg and this is an indication for fasciotomy.
There is a paucity of reports from our environment and despite numerous studies on the etiology, methods and techniques of compartment pressure measurement, pathophysiology and management of compartment syndrome,,,, very few highlighted the incidence., The aim of this study is to find out the prevalence and discuss the management of acute compartment syndrome of the limbs in our center in the Southeast region of Nigeria, from 2007 to 2015.
| Patients and Methods|| |
This work was approved by the Ethical Committee of the center having satisfied all issues about patients' confidentiality and the best practice methods concerning human research. There was no conflict of interests, and there was no monetary inducement concerning some products highlighted in the course of the discussion.
This is a retrospective study of patients admitted and treated for limb injuries between October 2007 and September 2015 by analyzing the relevant information contained in their medical case files as recorded.
This study was carried out in a private orthopedic and trauma center, located in a highly populated commercial city of Onitsha in the Southeast region of Nigeria, last estimated in 2015 by GeoNames geographical database to be 561,066. The center is a 25-bedded facility with a record of 92-100% bed occupancy in the last 3½ years. Intra-city road traffic accidents are common in the city because of its commercial nature, high population, the use of motorcycle (Okada), and more recently tricycle (Keke-Na-pepe) as modes of intra-city transport. This transport system is very lucrative in this bustling commercial city and young school leavers, retirees, and recently, the internally displaced persons from Boko Haram flight, many of who do not know how to ride these vehicles but jump at this opportunity to eke out a living. The result is a high rate of road traffic accidents and injuries to the vulnerable limbs. The patients who had significant injuries that needed admission were included in the study. These were the patients with limb/s fractures with or without other associated injuries, those with burns involving the limb/s, those with hemodynamic instability following their injuries and those with splints around their limbs. The patients with underlying vascular compromise such as diabetics or peripheral vascular disease or claudication were excluded from the study.
These patients were managed by a single orthopedic team consisting of a consultant orthopedic surgeon, a medical officer as well as the support staff. The diagnosis of compartment syndrome was made by clinical methods only. All of the 14 patients complained of excruciating pains that were out of proportion to their injuries and pains that were also not relieved by normal doses of the commonly used analgesics as recorded in the medical case files. Their involved limbs were swollen and tense. The investigations included full blood count, serum electrolyte urea, and creatinine before and after fasciotomies. Pulse oximetry SpO2 was used for monitoring. All of the patients had emergency fasciotomies under general anesthesia and subsequently, definitive treatments.
The patients' folders within the period of review were retrieved from the medical records using fracture, road traffic accident, falls from heights, burns, and bonesetters as search words. Further information was also obtained from the operation register master list. The data analyzed included the age, sex, diagnosis, etiology, the part of the limb affected, the treatments carried out, complications, and the duration of hospital stay.
Analysis was done with the Statistical Package for Social Sciences by International Business Machine (IBM-SPSS statistics for windows) version 20.0, Armonk NY, USA, 2011. Statistical significance was considered when P value is <0.05.
| Results|| |
The total number of patients with limb injuries admitted and treated within the period under review was 1362. [Table 1] below shows a statistically significant male predominance among all limb injuries, P < 0.05. The total number of patients with compartment syndrome resulting from their injuries was n = 14 (1.02%) with a slight male predominance that is not significant, P > 0.05 as shown in [Table 2]. The most common etiology was motorcycle accident n = 5 (35.7%) and the most common underlying pathology was fracture of the tibia n = 8 (57%), majority of which were close fracture n = 6 (43%). Young adults between the ages of 30 and 49 years n = 8 (57%) were mostly affected. The most common definitive treatment modality was delayed open reduction and internal fixation (ORIF) with split skin grafting (SSG) in one session. The range of hospital stay for the majority of the patients, especially those that had ORIF was 2-4 weeks n = 10 (71%).
|Table 1: Distribution of trauma patients admitted and treated according to etiology and gender |
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|Table 2: Cross table distribution of trauma patient and compartment syndrome with age and gender |
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The rarity of compartment syndrome is this study is depicted by a tiny speck in [Figure 1].
|Figure 1: Histogram showing distribution of compartment syndrome amongst the trauma cases according to the etiology|
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Majority of the patients were treated by delayed ORIF and SSG after the emergency fasciotomy as shown in [Table 3].
|Table 3: Cross-tabulation of compartment syndrome and injury type with the treatment carried out |
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The duration of hospital stay was mainly influenced by the definitive treatment carried out as shown in [Figure 2].
|Figure 2: Bar chart showing the number of patients with different fracture treatment methods and the duration of hospital stay|
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| Discussion|| |
Compartment syndrome is an uncommon surgical emergency. The incidence in this study is 1.02% despite the high number of limb injuries. Some authors reported 2%, and these lay credence to the rarity of this problem. However, Shore et al. reported a high rate of 11.6% among teenagers who had tibia fractures and this is expected, having grouped these high-risk patients together. Early diagnosis and emergency fasciotomy are absolutely necessary to reduce the chances of late complication of Volkmann's ischemic contracture and even more importantly to prevent the early complication of gangrene. Decompression must be adequate and on-table normalization of SpO2 often correlates with the adequacy of fasciotomy. Inadequate fasciotomy could give a false hope of treatment while the compartment syndrome progresses. Owing to our resource-poor setting, the diagnoses were made using clinical methods only. The simple hand-held compartment pressure measuring devices such as Stryker and Kodiak, which are improvement on the Whiteside technique, as mundane as they are in resource-rich centers, are not available in our center. When there is a clinical suspicion of acute compartment syndrome, the initial action will be to remove any external compressing materials such as bandages or splints and to elevate the leg to the level of the patient's heart. These were done for our patients with traditional bonesetters' splints. Higher elevation lowers the tissue perfusion pressure and worsens the ischemia. It is recommended that when in doubt, fasciotomy should be done, especially if the facilities for pressure measurement are not available. This is because the scar of fasciotomy wound is better than having contracture or losing a limb to gangrene due to late or misdiagnosis. It is also said that no one will blame the surgeon for carrying out fasciotomy, but everybody will blame the surgeon for missing the diagnosis of compartment syndrome.
In this study, half of the patients with acute compartment syndrome sustained their injuries from commercial motorcycle accidents. Tibia fracture constituted 57% of the patients with compartment pressure making the leg compartments the most affected. Some authors reported similar findings.,,, The compartment pressure rises when hematoma from tibia fracture increases the contents of the unyielding compartment. Compartment syndrome can occur in other organs that have investing fascia such as the foot, forearm, hand, arm, thigh, and buttock. The more voluminous the compartment with bigger space to accommodate hematomas and inflammatory exudates, the less the chances of symptomatic compartment pressure developing. Conversely, the tighter the compartment, the higher the chances of compartment syndrome occurring after injuries. Summarily, compartment syndrome is more common in the leg than in the thigh or arm. However, the few number of cases in this study is not possible for a strong statistical inference, and this is the limitation of this study.
Two patients out of the 12 patients who presented to our center with traditional bonesetters' splint in place had compartment syndrome (14.3%). The other 10 patients already had gangrene at the time of presentation, likely from a combination of unrecognized compartment syndrome and infection. It is difficult to ascertain the state of the limb before the splints were applied as the traditional bonesetters do not keep records and also do not refer patients. However, it is logical to assume that patients with tight splints in place in the presence of gangrene and coming from bonesetters' homes may have developed the gangrene most probably from compartment syndrome than from infections. Infections though usually present are more likely to be secondary from the effect of tight splints as well as from the smearing of contaminated earthen and herbal concoction on grazed skin. Nonetheless, infection could be complementary to the development of gangrene. Some reports have shown that tight traditional bonesetter's splint is a high-risk factor to developing gangrene from unrecognized progressive compartment syndrome that leads to amputation.,,,, Therefore, we recommend that any patient presenting early from bonesetter's home, especially with bonesetters' splint in place, should be assessed urgently and treated appropriately. One patient presented with a nearly circumferential tourniquet-like constricting burns eschar on the calf following an accident during which he sustained burns from exhaust pipe without fracture. Escharotomy was carried out.
Predominantly, more males were affected by these injuries, cutting across the different etiologies but only a slight male dominance in those with compartment syndrome. Some authors reported a significantly higher male dominance. This can only be explained by more male gender involvement in riskier activities in their quests for livelihood or recreation. This study also showed that the most common age bracket affected was 31-40 years and this is in conformity with the young active male age group.
Compartment syndrome complicates close tibia fractures more than it complicates open fractures. Out of the eight patients with compartment syndrome complicating tibia fracture, six were close fracture and two were Gustilo Type II open tibia fracture. The Type IIIa and IIIb fractures are less likely to be complicated by compartment syndrome because the large wounds allow the egress of hematoma. The definitive treatments that were carried out after the emergency fasciotomies depended on the underlying pathologies. The fracture could be fixed at the same time of fasciotomy if the materials, especially the implants are available under such emergency condition and if the limb is judged to be viable. The pulse oximetry SpO2 and the state of the muscles as evidenced by contractility, color, bleeding, and texture are veritable guides to the viability of the tissue. Macroscopically, none of the patient had significant muscle death, and their renal function remained normal after fasciotomies. In our center like in many resource-poor settings, there is usually no ready sterile implant pack from which a surgeon could choose from the assorted range to meet the demand that each emergency requires. Depending on the fracture configurations and level of contaminations, proper cast immobilization, percutaneous pin transfixation, or stabilization by external or internal fixation were the treatment modalities. As part of the definitive treatment, wound cover should be achieved as soon as it is possible to reduce the chances of infection. We covered the fasciotomy wounds mostly by split skin graft than by delayed primary or secondary suturing. There were few fasciotomy wound infections, especially those that had prolonged healing without grafting. They were also the patients that had large scars.
Reamed intramedullary nailing increases the intraosseous pressure but this is usually not enough to cause a significant rise in compartment pressure. It is therefore safe as a fracture fixation method in this condition. Interlocking nailing is preferable but intraoperative imaging control is absolutely necessary, especially when the instrumentation does not have a distal targeting external jig. Moreover, this method relies heavily on intact fracture hematoma for optimal fracture union, but when the hematoma had been evacuated as is usually the case during fasciotomy, this edge is lost. Open reduction and plating is a good option. Fasciotomy necessarily converts a close fracture to an open fracture, but since this is done in a controlled environment, it is safe to consider delayed open reduction and plating and wound cover as soon as it is possible to do so. Six out of the eight patients in our study with tibia fractures were treated initially by emergency fasciotomies, and then delayed plating combined with skin grafting within the next 72 h. Delayed plating was more feasible for us because one could not arrange for a primary implant operation within the limited time needed to carry out emergency fasciotomy. External fixation also increases compartment pressure and also not to the level of clinical significance. Patient treated by external fixations necessarily stayed longer in the hospital, 6-8 weeks, because their wounds needed to granulate and be certified free of infection before skin grafting. When there is no marked fracture displacement, and there are financial constraints, the treatment option of cast splintage for the fracture with or without percutaneous pinning can be effective. However, when compartment pressure complicates open fractures, especially those presenting several hours later with higher risks of potential contaminations or obvious wound infections, external fixation is the method of choice. None of the earlier patients in this study developed ischemic contracture on follow-ups.
| Conclusion|| |
Compartment syndrome is uncommon, but when it occurs, early recognition and emergency fasciotomy are necessary to salvage the threatened limb. The diagnosis must be kept in mind when severe pain that is out of proportion to the injury, especially tibia fracture occurs in a patient or when a patient with a traditional bonesetter's splint on the limb presents to the clinician.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]