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Incidence and predictors for the need for fasciotomy after extremity trauma: A 10-year review in a mature level I trauma centre
Injury, Int. J. Care Injured 42 (2011) 1157–1163
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Incidence and predictors for the need for fasciotomy after extremity trauma: A 10-year review in a mature level I trauma centre Bernardino C. Branco, Kenji Inaba *, Galinos Barmparas, Beat Schnu¨riger, Thomas Lustenberger, Peep Talving, Lydia Lam, Demetrios Demetriades Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 12 July 2010
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. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Extremity trauma Compartment syndrome Fasciotomy Incidence Predictors
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 [11,13–16,18]. Once diagnosed, fasciotomy is necessary to release the pressure within the compartment and prevent
* Corresponding author at: Division of Trauma and Surgical Critical Care, University of Southern California, 1200 North State Street, Room CL5100, Los Angeles, CA 90033-4525, USA. Tel.: +1 323 409 8597; fax: +1 323 441 9907. E-mail address: [email protected] (K. Inaba). 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.07.243
ischemic damage to muscles and neurovascular structures. CS is usually diagnosed clinically, however compartment pressure as well as perfusion pressure monitoring has also been used as important diagnostic tools to guide patient management [6,8,9,17]. Patients who are at risk of CS require serial physical examination, aggressive compartment pressure monitoring and a low threshold for fasciotomy. To the best of our knowledge, a study analysing injury and patient risk factors and their relationship to the need for fasciotomy after extremity trauma has not been yet been performed. The purpose of this study was to determine the incidence and predictors for the need for fasciotomy after extremity trauma.
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Fig. 1. Study outline.
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 Scale (GCS), Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), type and volume of blood products transfused and outcomes [need for
amputation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality]. Data was entered into a computerised spreadsheet (Microsoft Excel 2007, Microsoft corporation, Redmond, WA) and analysed using SPSS for Windowsß, version 12.0 (SPSS, Chicago, IL). Continuous variables were dichotomised using the following clinically relevant cut-points: age (55 vs. <55 years), systolic blood pressure (SBP) on admission (<90 vs. 90 mm Hg), GCS on admission (8 vs. >8), ISS (16 vs. <16) and AIS (3 vs. <3). All patients undergoing fasciotomy had a detailed review of their medical charts and operative records. Patients who sustained a fasciotomy in the absence of clinical signs and symptoms of CS were categorised as having a prophylactic fasciotomy.
Table 1 Characteristics of patients who required a fasciotomy in the absence of extremity trauma. Index
Sex
Injury mechanism
Fasciotomy location
ISS
Injury
PRBC
Plasma
Platelets
Initial management
HLOS
Outcome
1
M
GSW
Arm/arm/ leg/leg
16
IVC
65
37
6
Primary repair
72
2 3 4
M M M
Fall GSW GSW
Forearm/leg Leg/Leg Leg/leg
26 16 16
21 43 4
18 16 0
6 6 0
Primary repair IVC ligation Primary repair
16 1 14
5
M
GSW
Leg
17
Aorta IVC Aorta + renal artery Aorta + IVC + EIA + EIV
Forearm amputation + rehabilitation Death Death Home
Ukn
Ukn
Ukn
2
Death
6 7
M M
Fall GSW
Leg Leg
26 16
IVC IVC + EIA
Ukn 55
Ukn 24
Ukn 4
Arterial primary repair + nenous ligation IVC ligation Primary repair
23 49
8 9
M M
GSW GSW
Leg Leg
16 16
Aorta + IVC + EIA IVC + EIA + EIV
17 75
4 41
1 18
17 216
Rehabilitation Above knee amputation + home Home Rehabilitation
10
M
GSW
Leg
17
Ukn
Ukn
Ukn
6
Home
11
F
GSW
Leg
16
Aorta + bullet embolism to popliteal artery EIA + EIV
17
6
4
8
Home
12 13 14
M M M
GSW GSW MVA
Leg Leg Leg
50 16 10
IVC + EIA IVC + EIA EIA
33 88 28
10 71 13
6 29 10
1 9 71
Death Death Home
Primary repair IVC repair + aorta-femoral shunt + EIV ligation Primary repair + incision with removal of foreign body and primary repair Arterial primary repair + venous ligation Primary repair IVC ligation + PTFE graft Iliac-femoral shunt
ISS, Injury Severity Score; PRBC, packed red blood cells; HLOS, hospital length of stay; GSW, gunshot wound; IVC, inferior vena cava; EIA, external iliac artery; EIV, external iliac vein; MVA, motor vehicle accident; Ukn, unknown; PTFE, polytetrafluorethylene.
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Fig. 2. Decrease in fasciotomy utilisation throughout the study period.
Patients who required a fasciotomy were compared with those who did not for differences in demographics, clinical data, and outcomes using bivariate analysis. Chi-squared or Fisher’s exact tests were used to compare proportions, and unpaired student’s t or Mann–Whitney U tests were performed to compare means. To identify independent predictors for the need for fasciotomy after extremity trauma, a stepwise logistic regression was utilised and risk factors from the bivariate analysis with a p-value < 0.2 were included in the model. 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 fasciot-
omy due to CS; these patients all had major abdominal vascular injuries. The characteristics of these patients are presented in Table 1. During the study period, fasciotomy rate decreased significantly from 3.2% in 1998 to 2.5% in 2002 to 0.7% in 2007 (p-value for trend < 0.001) (Fig. 2). However, ISS and extremity AIS remained stable over the study period. Patients who required a fasciotomy were predominantly male (90.6% vs. 73.5%, p < 0.001), young (31.5 14.2 years vs. 35.6 18.2 years, p < 0.001), more hypotensive on admission (8.7% vs. 4.7%, p = 0.005), within higher ISS (14.5 9.7 vs. 12.8 10.6, p = 0.006) and were more likely to have an extremity AIS 3 (80.6% vs. 37.1%, p < 0.001). Patients who required a fasciotomy received significantly more units of PRBCs (8.2 13.9 vs. 1.8 5.1, p < 0.001), plasma (3.7 10.5 vs. 0.8 3.7, p < 0.001) and aphaeresis platelets (0.5 1.6 vs. 0.1 0.5, p < 0.001) during their hospital stay. Comparison of demographic, clinical data and transfusion requirements between patient groups is presented in Table 2.
Table 2 Demographic, clinical data and transfusion requirements of patient groups.
Male (%) Age (year), mean SD; [median], (range) Age 55 (%) Blunt (%) Intubated on ED (%) SBP on admission <90 mmHg (%) GCS on admission 8 (%) ISS, mean SD; [median], (range) ISS 16 (%) Head AIS 3 (%) Chest AIS 3 (%) Abdomen AIS 3 (%) Extremity AIS 3 (%) PRBC, mean SD; [median], (range) Plasma, mean SD; [median], (range) Platelets, mean SD; [median], (range)
Extremity trauma (n = 10,315)
Fasciotomy (n = 288)
No fasciotomy (n = 10,027)
p-Value
74.0% (7631) 35.5 18.1; [32], (1–101) 14.9% (1539) 82.5% (8514) 5.4% (551) 4.8% (494) 7.9% (804) 12.8 10.6; [9], (1–75) 25.3% (2612) 13.4% (1384) 16.4% (1695) 8.9% (915) 38.3% (3950) 2.0 5.7; [0], (0–101) 0.9 4.1; [0], (0–86) 0.1 0.5; [0], (0–19)
90.6% (261) 31.5 14.2; [28], (6–89) 6.9% (20) 51.0% (147) 3.1% (9) 8.7% (25) 6.6% (19) 14.5 9.7; [10], (1–75) 32.6% (94) 7.6% (22) 12.8% (37) 11.8% (34) 80.6% (232) 8.2 13.9; [4], (0–93) 3.7 10.5; [0], (0–86) 0.5 1.6; [0], (0–19)
73.5% (7370) 35.6 18.2; [32], (1–101) 15.1% (1519) 83.5% (8367) 5.4% (542) 4.7% (469) 7.9% (785) 12.8 10.6; [9], (1–75) 25.1% (2518) 13.6% (1362) 16.5% (1658) 8.8% (881) 37.1% (3718) 1.8 5.1; [0], (0–101) 0.8 3.7; [0], (0–86) 0.1 0.5; [0], (0–11)
<0.001* <0.001* <0.001* <0.001* 0.109 0.005* 0.499 0.006* 0.004* 0.004* 0.110 0.087 <0.001* <0.001* <0.001* <0.001*
The p-values for categorical variables were derived from chi-square or Fisher’s exact tests; p-values for continuous variables were derived from unpaired Student’s t or Mann– Whitney U tests. SD, standard deviation; ED, emergency department; SBP, systolic blood pressure; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; AIS, Abbreviated Injury Scale; PRBC, packed red blood cells. * p-Values are significantly different (p < 0.05).
[(Fig._3)TD$IG]
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Fig. 3. Anatomic distribution of fasciotomies.
A total of 315 fasciotomies were performed. This included 67 upper extremity fasciotomies in 66 patients and 248 lower extremity fasciotomies in 237 patients. The most common type of fasciotomy performed was below knee leg (68.4%), followed by forearm (14.4%) and thigh (8.9%) (Fig. 3). The incidence of fasciotomy varied widely by mechanism of injury (from 0.9% after a motor vehicle collision to 8.6% after a GSW, p-value for trend < 0.001) and by type of injury (from 2.2% in closed fracture to 41.8% in combined vascular injury, p-value for trend < 0.001) (Figs. 4 and 5).
[(Fig._4)TD$IG]
Patients who required a 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); 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); and upper and lower extremity nerve injuries (8.7% vs. 2.5%, p < 0.001 and 4.2% vs. 0.6%, p < 0.001, respectively) (Table 3). When outcomes were compared between patients who required a fasciotomy and those who did not, there was trend
Fig. 4. Incidence of fasciotomy by mechanism of injury.
[(Fig._5)TD$IG]
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Fig. 5. Incidence of fasciotomy by injury type.
Table 3 Injuries of patient groups.
Upper extremity closed fracture (%) Upper extremity open fracture (%) Elbow dislocation (%) Axillary vessels (%) Brachial vessels (%) Radial vessels (%) Ulnar vessels (%) Upper extremity nerve (%) Lower extremity closed fracture (%) Lower extremity open fracture (%) Knee dislocation (%) External iliac vessels (%) Femoral vessels (%) Popliteal vessels (%) Tibial vessels (%) Lower extremity nerve (%)
Extremity trauma (n = 10,315)
Fasciotomy (n = 288)
No fasciotomy (n = 10,027)
p-Value
14.2% 5.3% 8.8% 0.3% 1.3% 0.8% 0.6% 2.6% 22.5% 12.2% 7.2% 1.0% 1.7% 0.8% 0.2% 0.7%
10.8% 8.3% 25.0% 0.7% 8.0% 3.8% 2.1% 8.7% 23.3% 28.5% 31.2% 5.2% 20.1% 15.3% 3.1% 4.2%
14.3% 5.2% 8.3% 0.3% 1.1% 0.7% 0.6% 2.5% 22.5% 11.8% 6.5% 0.9% 1.1% 0.4% 0.1% 0.6%
0.107 0.031* 0.005* 0.204 <0.001* <0.001* 0.009* <0.001* 0.779 <0.001* <0.001* <0.001* <0.001* <0.001* <0.001* <0.001*
(1467) (544) (95) (30) (134) (84) (65) (272) (2326) (1262) (78) (105) (172) (80) (23) (77)
(31) (24) (8) (2) (23) (11) (6) (25) (67) (82) (10) (15) (58) (44) (9) (12)
(1436) (520) (87) (28) (111) (73) (59) (247) (2259) (1180) (68) (90) (114) (36) (14) (65)
The p-values for categorical variables were derived from chi-square or Fisher‘s exact tests. * p-Values are significantly different (p < 0.05).
Table 4 Predictors of fasciotomy after extremity trauma. Step
Variable
Fasciotomy
R2
Adjusted odds ratio 95% (CI)
p-Value
1 2 3 4 5 6 7 8 9 10
Arterial injury PRBC transfusion Venous injury Male Open fracture Dislocation elbow/knee Combined vascular injury GSW ISS 16 Age < 55 years
27.2% 6.5% 23.4% 3.4% 5.9% 10.4% 41.8% 8.6% 3.6% 3.1%
0.20 0.05 0.04 0.01 0.01 0.01 0.01 0.01 0.01 0.01
10.4 4.6 7.4 2.2 1.8 3.5 3.0 1.8 1.5 1.8
<0.001* <0.001* <0.001* 0.001* 0.001* <0.001* 0.003* 0.008* 0.024* 0.032*
(7.1, (3.2, (4.5, (1.4, (1.3, (1.8, (1.4, (1.2, (1.1, (1.1,
15.4) 6.3) 12.4) 3.5) 2.4) 6.8) 6.1) 2.9) 2.0) 3.0)
A total of 6237 subjects with complete data were included in the model. The R2 for the model was 36%. Variables entered in the regression: gender, age, mechanism of injury, SBP <90 mmHg, ISS 16, PRBC transfusion, closed fracture, open fracture, knee/elbow dislocation, nerve injury, venous injury, arterial injury, combined vascular injury. CI, confidence interval; PRBC, packed red blood cells; GSW, gunshot wound; ISS, Injury Severity Score. * p-Values are significantly different (p < 0.05).
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towards higher rates of amputation in patients who required a fasciotomy (7.3% vs. 1.3%, adjusted p = 0.227). There was no difference in mortality (5.6% vs. 6.4%, adjusted p = 0.121) or ICU LOS (8.1 9.4 vs. 9.7 12.1, adjusted p = 0.110). Patients who required a fasciotomy had a longer hospital LOS (18.7 20.0 vs. 9.1 14.7, adjusted p < 0.001). A stepwise logistic regression identified the presence of vascular injury (arterial, venous or combined), 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 after extremity trauma (Table 4). 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 [11,13–16,18]. 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 diagnostic tools to guide patient management [6,8,9,17]. The identification of patients at highest risk of developing CS may facilitate the early recognition and treatment of CS. The present study targeted 2 key questions. First, what is the rate of fasciotomy after extremity injury in the trauma population? And secondly, what predictors, if any, are associated with the need for fasciotomy after extremity trauma? With regards to the former question, we found that the overall incidence of fasciotomy after extremity trauma is low (2.8%). However, it varied depending on the injury mechanism and type. Patients who had a penetrating injury mechanism had higher rates of fasciotomy. Those with gunshot wounds in particular had a fasciotomy rate of 8.6%. Patients who sustained vascular injuries also had high fasciotomy rates. If combined arterial and venous injury was present, the need for fasciotomy exceeded 40%. With regards to the predictive factors, we identified 10 risk factors associated with the need for fasciotomy after extremity trauma. Young males who sustain penetrating or multi-system trauma (ISS 16), requiring blood transfusion, with open fractures, elbow or knee dislocations or vascular injury (arterial, venous or combined) are at highest risk of requiring a fasciotomy after extremity trauma. In previous studies, certain injury patterns have been associated with a higher likelihood of CS and need for fasciotomy. Gonzalez et al. found that penetrating injuries to the proximal half of the leg are the most common cause of compartment syndrome in the lower extremity [5]. Abouezzi et al. found a 28% fasciotomy rate in patients with peripheral vascular injuries treated at a Level I trauma centre. The rate of therapeutic fasciotomy after injury to the popliteal vessels, in particular, was 62% [1]. A recent study performed at the Baylor College of Medicine analysing 139 patients who sustained brachial artery injuries found an overall rate of CS requiring surgical intervention of 20.9%. Three major independent risk factors that correlated with the development of CS and need for fasciotomy were identified: significant intra-operative blood loss, presence of open fracture and concomitant arterial injury [10]. For patients sustaining extremity injury, the presence of these risk factors should result in careful monitoring of the limb for the development of CS. The presence of an arterial injury and the need for blood transfusion in particular increased the odds of requiring a fasciotomy by 10.4 and 4.6 fold, respectively. Patients with these factors in particular should heighten surgeon suspicion for CS. These patients may benefit from serial physical examination and aggressive pressure monitoring with a low threshold for fasciotomy.
It is also important to realise that CS can occur in the absence of extremity trauma. We identified 14 patients who developed CS requiring a fasciotomy without injury to an extremity. This ‘‘secondary’’ extremity CS has been described and, as noted in the description of our patients, occurs in those severely injured who require massive amounts of blood products [4]. In the present study, all of these sustained severe abdominal trauma with associated vascular injuries (i.e., aorta, inferior vena cava and iliac vessels). The mean number of units of PRBC, plasma and platelets that these patients received during their hospital stay was 37.0 20.5, 20.0 9.3 and 9.0 5.4, respectively. Not surprisingly, the amputation and mortality rates among these patients were high (14% and 36%, respectively). To the best of our knowledge this is the largest series to date scrutinising fasciotomy following extremity trauma. Nevertheless, there are several limitations of our study, it is retrospective and therefore contained biases that would be less likely to occur in a prospective study including sample and recall biases. At our institution, the diagnosis of CS was based primarily on physical examination. Objective intra-compartmental pressure data and the identification of specific compartments that required fasciotomy were therefore not available for analysis. By observing the incidence trend over the study period, after 2004, fasciotomy rate decreased steadily. Although the exact reasons for this remain unknown, we can hypothesise some possible causes: (1) Minimised crystalloid infusion: Resuscitation strategies utilising crystalloid infusion have shown to impact neutrophil activation leading to exacerbated systemic inflammatory response [2,12]. During the study period, crystalloid infusion has been minimised as resuscitation strategies have evolved towards blood replacement therapy. Although crystalloid infusion was not available for analysis in this cohort, it is possible that a difference in the volume of crystalloids received by patients admitted in the early and late study periods may have been responsible for this decrease in fasciotomy rates. (2) Mannitol usage: Mannitol has been shown to decrease the need for fasciotomy especially in those with mild compartmental pressures [3,7]. In this study, mannitol infusion data was also not available for analysis. It is possible that a difference in mannitol infusion during the study period may have been responsible for this decrease in fasciotomy rates. In summary, the present study reports the incidence and predictors for the need for fasciotomy after extremity trauma. We identified 10,315 patients who sustained extremity trauma, of which approximately 1% 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.The incidence of fasciotomy varied widely by injury mechanism and type. The presence of vascular injury, in particular combined arterial and venous injuries, the need for PRBC transfusion, male gender, open fractures, elbow or knee dislocations, GSW, ISS 16 and age < 55 years were identified as independent predictors for the need for fasciotomy. Conflict of interest We have no conflict of interest to disclose. References [1] Abouezzi Z, Nassoura Z, Ivatury RR, et al. A critical reappraisal of indications for fasciotomy after extremity vascular trauma. Arch Surg 1998;133:547–51. [2] Alam HB, Stanton K, Koustova E, et al. Effect of different resuscitation strategies on neutrophil activation in a swine model of hemorrhagic shock. Resuscitation 2004;60:91–9.
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Injury journal homepage: www.elsevier.com/locate/injury
Incidence and predictors for the need for fasciotomy after extremity trauma: A 10-year review in a mature level I trauma centre Bernardino C. Branco, Kenji Inaba *, Galinos Barmparas, Beat Schnu¨riger, Thomas Lustenberger, Peep Talving, Lydia Lam, Demetrios Demetriades Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 12 July 2010
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. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Extremity trauma Compartment syndrome Fasciotomy Incidence Predictors
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 [11,13–16,18]. Once diagnosed, fasciotomy is necessary to release the pressure within the compartment and prevent
* Corresponding author at: Division of Trauma and Surgical Critical Care, University of Southern California, 1200 North State Street, Room CL5100, Los Angeles, CA 90033-4525, USA. Tel.: +1 323 409 8597; fax: +1 323 441 9907. E-mail address: [email protected] (K. Inaba). 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.07.243
ischemic damage to muscles and neurovascular structures. CS is usually diagnosed clinically, however compartment pressure as well as perfusion pressure monitoring has also been used as important diagnostic tools to guide patient management [6,8,9,17]. Patients who are at risk of CS require serial physical examination, aggressive compartment pressure monitoring and a low threshold for fasciotomy. To the best of our knowledge, a study analysing injury and patient risk factors and their relationship to the need for fasciotomy after extremity trauma has not been yet been performed. The purpose of this study was to determine the incidence and predictors for the need for fasciotomy after extremity trauma.
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Fig. 1. Study outline.
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 Scale (GCS), Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), type and volume of blood products transfused and outcomes [need for
amputation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality]. Data was entered into a computerised spreadsheet (Microsoft Excel 2007, Microsoft corporation, Redmond, WA) and analysed using SPSS for Windowsß, version 12.0 (SPSS, Chicago, IL). Continuous variables were dichotomised using the following clinically relevant cut-points: age (55 vs. <55 years), systolic blood pressure (SBP) on admission (<90 vs. 90 mm Hg), GCS on admission (8 vs. >8), ISS (16 vs. <16) and AIS (3 vs. <3). All patients undergoing fasciotomy had a detailed review of their medical charts and operative records. Patients who sustained a fasciotomy in the absence of clinical signs and symptoms of CS were categorised as having a prophylactic fasciotomy.
Table 1 Characteristics of patients who required a fasciotomy in the absence of extremity trauma. Index
Sex
Injury mechanism
Fasciotomy location
ISS
Injury
PRBC
Plasma
Platelets
Initial management
HLOS
Outcome
1
M
GSW
Arm/arm/ leg/leg
16
IVC
65
37
6
Primary repair
72
2 3 4
M M M
Fall GSW GSW
Forearm/leg Leg/Leg Leg/leg
26 16 16
21 43 4
18 16 0
6 6 0
Primary repair IVC ligation Primary repair
16 1 14
5
M
GSW
Leg
17
Aorta IVC Aorta + renal artery Aorta + IVC + EIA + EIV
Forearm amputation + rehabilitation Death Death Home
Ukn
Ukn
Ukn
2
Death
6 7
M M
Fall GSW
Leg Leg
26 16
IVC IVC + EIA
Ukn 55
Ukn 24
Ukn 4
Arterial primary repair + nenous ligation IVC ligation Primary repair
23 49
8 9
M M
GSW GSW
Leg Leg
16 16
Aorta + IVC + EIA IVC + EIA + EIV
17 75
4 41
1 18
17 216
Rehabilitation Above knee amputation + home Home Rehabilitation
10
M
GSW
Leg
17
Ukn
Ukn
Ukn
6
Home
11
F
GSW
Leg
16
Aorta + bullet embolism to popliteal artery EIA + EIV
17
6
4
8
Home
12 13 14
M M M
GSW GSW MVA
Leg Leg Leg
50 16 10
IVC + EIA IVC + EIA EIA
33 88 28
10 71 13
6 29 10
1 9 71
Death Death Home
Primary repair IVC repair + aorta-femoral shunt + EIV ligation Primary repair + incision with removal of foreign body and primary repair Arterial primary repair + venous ligation Primary repair IVC ligation + PTFE graft Iliac-femoral shunt
ISS, Injury Severity Score; PRBC, packed red blood cells; HLOS, hospital length of stay; GSW, gunshot wound; IVC, inferior vena cava; EIA, external iliac artery; EIV, external iliac vein; MVA, motor vehicle accident; Ukn, unknown; PTFE, polytetrafluorethylene.
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Fig. 2. Decrease in fasciotomy utilisation throughout the study period.
Patients who required a fasciotomy were compared with those who did not for differences in demographics, clinical data, and outcomes using bivariate analysis. Chi-squared or Fisher’s exact tests were used to compare proportions, and unpaired student’s t or Mann–Whitney U tests were performed to compare means. To identify independent predictors for the need for fasciotomy after extremity trauma, a stepwise logistic regression was utilised and risk factors from the bivariate analysis with a p-value < 0.2 were included in the model. 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 fasciot-
omy due to CS; these patients all had major abdominal vascular injuries. The characteristics of these patients are presented in Table 1. During the study period, fasciotomy rate decreased significantly from 3.2% in 1998 to 2.5% in 2002 to 0.7% in 2007 (p-value for trend < 0.001) (Fig. 2). However, ISS and extremity AIS remained stable over the study period. Patients who required a fasciotomy were predominantly male (90.6% vs. 73.5%, p < 0.001), young (31.5 14.2 years vs. 35.6 18.2 years, p < 0.001), more hypotensive on admission (8.7% vs. 4.7%, p = 0.005), within higher ISS (14.5 9.7 vs. 12.8 10.6, p = 0.006) and were more likely to have an extremity AIS 3 (80.6% vs. 37.1%, p < 0.001). Patients who required a fasciotomy received significantly more units of PRBCs (8.2 13.9 vs. 1.8 5.1, p < 0.001), plasma (3.7 10.5 vs. 0.8 3.7, p < 0.001) and aphaeresis platelets (0.5 1.6 vs. 0.1 0.5, p < 0.001) during their hospital stay. Comparison of demographic, clinical data and transfusion requirements between patient groups is presented in Table 2.
Table 2 Demographic, clinical data and transfusion requirements of patient groups.
Male (%) Age (year), mean SD; [median], (range) Age 55 (%) Blunt (%) Intubated on ED (%) SBP on admission <90 mmHg (%) GCS on admission 8 (%) ISS, mean SD; [median], (range) ISS 16 (%) Head AIS 3 (%) Chest AIS 3 (%) Abdomen AIS 3 (%) Extremity AIS 3 (%) PRBC, mean SD; [median], (range) Plasma, mean SD; [median], (range) Platelets, mean SD; [median], (range)
Extremity trauma (n = 10,315)
Fasciotomy (n = 288)
No fasciotomy (n = 10,027)
p-Value
74.0% (7631) 35.5 18.1; [32], (1–101) 14.9% (1539) 82.5% (8514) 5.4% (551) 4.8% (494) 7.9% (804) 12.8 10.6; [9], (1–75) 25.3% (2612) 13.4% (1384) 16.4% (1695) 8.9% (915) 38.3% (3950) 2.0 5.7; [0], (0–101) 0.9 4.1; [0], (0–86) 0.1 0.5; [0], (0–19)
90.6% (261) 31.5 14.2; [28], (6–89) 6.9% (20) 51.0% (147) 3.1% (9) 8.7% (25) 6.6% (19) 14.5 9.7; [10], (1–75) 32.6% (94) 7.6% (22) 12.8% (37) 11.8% (34) 80.6% (232) 8.2 13.9; [4], (0–93) 3.7 10.5; [0], (0–86) 0.5 1.6; [0], (0–19)
73.5% (7370) 35.6 18.2; [32], (1–101) 15.1% (1519) 83.5% (8367) 5.4% (542) 4.7% (469) 7.9% (785) 12.8 10.6; [9], (1–75) 25.1% (2518) 13.6% (1362) 16.5% (1658) 8.8% (881) 37.1% (3718) 1.8 5.1; [0], (0–101) 0.8 3.7; [0], (0–86) 0.1 0.5; [0], (0–11)
<0.001* <0.001* <0.001* <0.001* 0.109 0.005* 0.499 0.006* 0.004* 0.004* 0.110 0.087 <0.001* <0.001* <0.001* <0.001*
The p-values for categorical variables were derived from chi-square or Fisher’s exact tests; p-values for continuous variables were derived from unpaired Student’s t or Mann– Whitney U tests. SD, standard deviation; ED, emergency department; SBP, systolic blood pressure; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; AIS, Abbreviated Injury Scale; PRBC, packed red blood cells. * p-Values are significantly different (p < 0.05).
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Fig. 3. Anatomic distribution of fasciotomies.
A total of 315 fasciotomies were performed. This included 67 upper extremity fasciotomies in 66 patients and 248 lower extremity fasciotomies in 237 patients. The most common type of fasciotomy performed was below knee leg (68.4%), followed by forearm (14.4%) and thigh (8.9%) (Fig. 3). The incidence of fasciotomy varied widely by mechanism of injury (from 0.9% after a motor vehicle collision to 8.6% after a GSW, p-value for trend < 0.001) and by type of injury (from 2.2% in closed fracture to 41.8% in combined vascular injury, p-value for trend < 0.001) (Figs. 4 and 5).
[(Fig._4)TD$IG]
Patients who required a 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); 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); and upper and lower extremity nerve injuries (8.7% vs. 2.5%, p < 0.001 and 4.2% vs. 0.6%, p < 0.001, respectively) (Table 3). When outcomes were compared between patients who required a fasciotomy and those who did not, there was trend
Fig. 4. Incidence of fasciotomy by mechanism of injury.
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Fig. 5. Incidence of fasciotomy by injury type.
Table 3 Injuries of patient groups.
Upper extremity closed fracture (%) Upper extremity open fracture (%) Elbow dislocation (%) Axillary vessels (%) Brachial vessels (%) Radial vessels (%) Ulnar vessels (%) Upper extremity nerve (%) Lower extremity closed fracture (%) Lower extremity open fracture (%) Knee dislocation (%) External iliac vessels (%) Femoral vessels (%) Popliteal vessels (%) Tibial vessels (%) Lower extremity nerve (%)
Extremity trauma (n = 10,315)
Fasciotomy (n = 288)
No fasciotomy (n = 10,027)
p-Value
14.2% 5.3% 8.8% 0.3% 1.3% 0.8% 0.6% 2.6% 22.5% 12.2% 7.2% 1.0% 1.7% 0.8% 0.2% 0.7%
10.8% 8.3% 25.0% 0.7% 8.0% 3.8% 2.1% 8.7% 23.3% 28.5% 31.2% 5.2% 20.1% 15.3% 3.1% 4.2%
14.3% 5.2% 8.3% 0.3% 1.1% 0.7% 0.6% 2.5% 22.5% 11.8% 6.5% 0.9% 1.1% 0.4% 0.1% 0.6%
0.107 0.031* 0.005* 0.204 <0.001* <0.001* 0.009* <0.001* 0.779 <0.001* <0.001* <0.001* <0.001* <0.001* <0.001* <0.001*
(1467) (544) (95) (30) (134) (84) (65) (272) (2326) (1262) (78) (105) (172) (80) (23) (77)
(31) (24) (8) (2) (23) (11) (6) (25) (67) (82) (10) (15) (58) (44) (9) (12)
(1436) (520) (87) (28) (111) (73) (59) (247) (2259) (1180) (68) (90) (114) (36) (14) (65)
The p-values for categorical variables were derived from chi-square or Fisher‘s exact tests. * p-Values are significantly different (p < 0.05).
Table 4 Predictors of fasciotomy after extremity trauma. Step
Variable
Fasciotomy
R2
Adjusted odds ratio 95% (CI)
p-Value
1 2 3 4 5 6 7 8 9 10
Arterial injury PRBC transfusion Venous injury Male Open fracture Dislocation elbow/knee Combined vascular injury GSW ISS 16 Age < 55 years
27.2% 6.5% 23.4% 3.4% 5.9% 10.4% 41.8% 8.6% 3.6% 3.1%
0.20 0.05 0.04 0.01 0.01 0.01 0.01 0.01 0.01 0.01
10.4 4.6 7.4 2.2 1.8 3.5 3.0 1.8 1.5 1.8
<0.001* <0.001* <0.001* 0.001* 0.001* <0.001* 0.003* 0.008* 0.024* 0.032*
(7.1, (3.2, (4.5, (1.4, (1.3, (1.8, (1.4, (1.2, (1.1, (1.1,
15.4) 6.3) 12.4) 3.5) 2.4) 6.8) 6.1) 2.9) 2.0) 3.0)
A total of 6237 subjects with complete data were included in the model. The R2 for the model was 36%. Variables entered in the regression: gender, age, mechanism of injury, SBP <90 mmHg, ISS 16, PRBC transfusion, closed fracture, open fracture, knee/elbow dislocation, nerve injury, venous injury, arterial injury, combined vascular injury. CI, confidence interval; PRBC, packed red blood cells; GSW, gunshot wound; ISS, Injury Severity Score. * p-Values are significantly different (p < 0.05).
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towards higher rates of amputation in patients who required a fasciotomy (7.3% vs. 1.3%, adjusted p = 0.227). There was no difference in mortality (5.6% vs. 6.4%, adjusted p = 0.121) or ICU LOS (8.1 9.4 vs. 9.7 12.1, adjusted p = 0.110). Patients who required a fasciotomy had a longer hospital LOS (18.7 20.0 vs. 9.1 14.7, adjusted p < 0.001). A stepwise logistic regression identified the presence of vascular injury (arterial, venous or combined), 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 after extremity trauma (Table 4). 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 [11,13–16,18]. 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 diagnostic tools to guide patient management [6,8,9,17]. The identification of patients at highest risk of developing CS may facilitate the early recognition and treatment of CS. The present study targeted 2 key questions. First, what is the rate of fasciotomy after extremity injury in the trauma population? And secondly, what predictors, if any, are associated with the need for fasciotomy after extremity trauma? With regards to the former question, we found that the overall incidence of fasciotomy after extremity trauma is low (2.8%). However, it varied depending on the injury mechanism and type. Patients who had a penetrating injury mechanism had higher rates of fasciotomy. Those with gunshot wounds in particular had a fasciotomy rate of 8.6%. Patients who sustained vascular injuries also had high fasciotomy rates. If combined arterial and venous injury was present, the need for fasciotomy exceeded 40%. With regards to the predictive factors, we identified 10 risk factors associated with the need for fasciotomy after extremity trauma. Young males who sustain penetrating or multi-system trauma (ISS 16), requiring blood transfusion, with open fractures, elbow or knee dislocations or vascular injury (arterial, venous or combined) are at highest risk of requiring a fasciotomy after extremity trauma. In previous studies, certain injury patterns have been associated with a higher likelihood of CS and need for fasciotomy. Gonzalez et al. found that penetrating injuries to the proximal half of the leg are the most common cause of compartment syndrome in the lower extremity [5]. Abouezzi et al. found a 28% fasciotomy rate in patients with peripheral vascular injuries treated at a Level I trauma centre. The rate of therapeutic fasciotomy after injury to the popliteal vessels, in particular, was 62% [1]. A recent study performed at the Baylor College of Medicine analysing 139 patients who sustained brachial artery injuries found an overall rate of CS requiring surgical intervention of 20.9%. Three major independent risk factors that correlated with the development of CS and need for fasciotomy were identified: significant intra-operative blood loss, presence of open fracture and concomitant arterial injury [10]. For patients sustaining extremity injury, the presence of these risk factors should result in careful monitoring of the limb for the development of CS. The presence of an arterial injury and the need for blood transfusion in particular increased the odds of requiring a fasciotomy by 10.4 and 4.6 fold, respectively. Patients with these factors in particular should heighten surgeon suspicion for CS. These patients may benefit from serial physical examination and aggressive pressure monitoring with a low threshold for fasciotomy.
It is also important to realise that CS can occur in the absence of extremity trauma. We identified 14 patients who developed CS requiring a fasciotomy without injury to an extremity. This ‘‘secondary’’ extremity CS has been described and, as noted in the description of our patients, occurs in those severely injured who require massive amounts of blood products [4]. In the present study, all of these sustained severe abdominal trauma with associated vascular injuries (i.e., aorta, inferior vena cava and iliac vessels). The mean number of units of PRBC, plasma and platelets that these patients received during their hospital stay was 37.0 20.5, 20.0 9.3 and 9.0 5.4, respectively. Not surprisingly, the amputation and mortality rates among these patients were high (14% and 36%, respectively). To the best of our knowledge this is the largest series to date scrutinising fasciotomy following extremity trauma. Nevertheless, there are several limitations of our study, it is retrospective and therefore contained biases that would be less likely to occur in a prospective study including sample and recall biases. At our institution, the diagnosis of CS was based primarily on physical examination. Objective intra-compartmental pressure data and the identification of specific compartments that required fasciotomy were therefore not available for analysis. By observing the incidence trend over the study period, after 2004, fasciotomy rate decreased steadily. Although the exact reasons for this remain unknown, we can hypothesise some possible causes: (1) Minimised crystalloid infusion: Resuscitation strategies utilising crystalloid infusion have shown to impact neutrophil activation leading to exacerbated systemic inflammatory response [2,12]. During the study period, crystalloid infusion has been minimised as resuscitation strategies have evolved towards blood replacement therapy. Although crystalloid infusion was not available for analysis in this cohort, it is possible that a difference in the volume of crystalloids received by patients admitted in the early and late study periods may have been responsible for this decrease in fasciotomy rates. (2) Mannitol usage: Mannitol has been shown to decrease the need for fasciotomy especially in those with mild compartmental pressures [3,7]. In this study, mannitol infusion data was also not available for analysis. It is possible that a difference in mannitol infusion during the study period may have been responsible for this decrease in fasciotomy rates. In summary, the present study reports the incidence and predictors for the need for fasciotomy after extremity trauma. We identified 10,315 patients who sustained extremity trauma, of which approximately 1% 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.The incidence of fasciotomy varied widely by injury mechanism and type. The presence of vascular injury, in particular combined arterial and venous injuries, the need for PRBC transfusion, male gender, open fractures, elbow or knee dislocations, GSW, ISS 16 and age < 55 years were identified as independent predictors for the need for fasciotomy. Conflict of interest We have no conflict of interest to disclose. References [1] Abouezzi Z, Nassoura Z, Ivatury RR, et al. A critical reappraisal of indications for fasciotomy after extremity vascular trauma. Arch Surg 1998;133:547–51. [2] Alam HB, Stanton K, Koustova E, et al. Effect of different resuscitation strategies on neutrophil activation in a swine model of hemorrhagic shock. Resuscitation 2004;60:91–9.
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