GOAL
This CPG provides an overview of acute extremity Compartment Syndrome (CS) and present a standardized approach to guide providers in the evaluation and treatment of patients with extremity war wounds, including the role of prophylactic and therapeutic fasciotomy.
BACKGROUND
CS is a common, controversial, and disabling problem in extremity war injuries. Seven to 11% of civilian tibia fractures result in compartment syndrome.1-5 A similar incidence can be expected in cases of fractures from non-battle injuries in deployed areas. In contrast, combat injuries often involve a higher overall trauma burden; extreme transfusion requirements; extensive soft tissue injuries; associated arterial injuries; multi-level limb trauma; and occur in remote locations. This results in fifteen percent of all military orthopaedic trauma casualties requiring at least one prophylactic or therapeutic fasciotomy.6
Recent research indicates proper detection of Compartment Syndrome (CS) is lifesaving and delay in diagnosis can be lethal.7 The operational definition of CS is a clinical syndrome wherein high pressure within a myofascial space reduces perfusion and decreases tissue viability. Therapeutic fasciotomy is indicated for established CS, and prophylactic fasciotomy is indicated when there is a substantial risk of compartment syndrome.8-10 Fasciotomy during the lag phase between injury and syndrome onset is prophylactic. Early detection is challenging, so prophylactic fasciotomy should be routine when compartment syndrome is likely. Prophylactic fasciotomy is most commonly indicated in patients with certain “at risk” fractures and in patients with prolonged ischemia or following limb reperfusion. Injury, treatment, and casualty variables affect risk (Tables 1 and 3) and may be interrelated.7-13 The difficulties associated with monitoring a patient’s physical exam during lengthy periods of transport must be considered in the decision to perform prophylactic fasciotomy, along with the inability to intervene surgically during Aeromedical Evacuation (AE).
The main factors are limb injury severity (particularly vessel injuries) and overall casualty injury severity (particularly shock) with a lesser factor being aggressive resuscitation (particularly >5 liters of crystalloid). Tissue edema and subsequent swelling due to injury maximizes in 1 to 2 days. Additional swelling from post-injury ischemia reperfusion (e.g., revascularization, shock, and tourniquet use) appears to delay the maximal time of limb swelling further; perhaps to 2 to 5 days post injury. High altitude (including normal AE aircraft cabin pressure), in and of itself, is not a contributor to compartment syndrome (Ritenour, et al). Compartment syndrome can lead to significant morbidity and mortality (Table 2). Surveys indicate surgeons with more training and experience, are more willing to perform fasciotomy. Once the decision is made to perform a prophylactic or therapeutic fasciotomy, a complete fasciotomy must be performed.14 There is evidence to support complete compartment release by full-length skin and fascial incisions as being superior to limited fasciotomy. Incomplete fasciotomy, a clearly preventable problem, risks worsened patient morbidity, mortality, and functional outcome.