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The impact of lower leg compartment syndrome on health related quality of life
Injury, Int. J. Care Injured 33 (2002) 117– 121 www.elsevier.com/locate/injury
The impact of lower leg compartment syndrome on health related quality of life P.V. Giannoudis a,*, C. Nicolopoulos a, H. Dinopoulos b, A. Ng a, S. Adedapo b, P. Kind c a
Le6el 5, C.S.B., Department of Orthopaedics and Trauma, Uni6ersity of Leeds, St James’s Hospital, Beckett Street, Leeds LS9 7TF, UK b Department of Orthopaedics and Trauma, Bradford Royal Infirmary, Bradford BD9 6RJ, UK c Centre for Health Economics, Uni6ersity of York, York YO1 5DD, UK Accepted 11 May 2001
Abstract Although the aetiology, pathophysiology and treatment of acute compartment syndrome have been well described in the literature, there is limited information on the long-term impact of compartment syndrome on quality of life. We reviewed the medical records and radiographs of all the patients treated with surgical decompression of compartment syndrome. Between 1993 and 1998, 42 cases were identified. There were 30 cases of tibial compartment syndrome and 12 cases involving other limbs. These 30 patients were recalled for a follow-up assessment during which they were asked to complete an EQ-5D (EuroQol), a standardised measure of health related quality of life based on five dimensions (self-care, pain/discomfort, mobility, usual activities and anxiety/depression). Patients were compared with EQ-5D age/sex norms derived from a randomly selected group of patients that had sustained isolated closed tibial shaft fractures. The minimum follow-up time was 12 months. Patients who stated that the appearance of the surgical site was a problem, reported significantly poorer health related quality of life than did patients who had no problem with the appearance. Patients with skin graft reported more problems with pain and discomfort than patients without skin graft. Patients with faster closure times of the wound showed significantly better self-rated health status than patients in whom the wound closure time was longer. Although the patients in this study reported significantly more problems on the dimensions of EQ-5D than were reported in the control group, their overall self-rated health was not statistically different. This study has demonstrated that compartment syndrome may be associated with long-term impact on health related quality of life. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction Acute compartment syndrome of the lower extremity is a condition that requires immediate surgical treatment. The clinical diagnosis may occasionally be obvious but sometimes the findings are not apparent. Failure or delay in reaching the diagnosis of acute compartment syndrome may lead to irreparable damage to muscle or nerve leading to poor long-term function [1,2]. Despite the increased clinical awareness of the condition, it continues to be a significant cause of * Corresponding author. Tel.: + 44-113-2433-144x65222. E-mail address: [email protected] (P.V. Giannoudis).
morbidity among trauma patients [3,4]. Although the aetiology, pathophysiology and treatment of acute compartment syndrome have been well described in the literature [5–8], there is limited knowledge of the longterm impact of compartment syndrome on the quality of life of patients. The incidence of ischaemic contractures as a complication of tibial fractures has been reported to be : 2%, however, the long-term effect of this is not known [9]. Accordingly, we reviewed all the cases of compartment syndrome in our institution in order to assess the long-term outcome as per the quality of life of patients following early decompression of an acute compartment syndrome.
0020-1383/02/$ - see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 0 7 3 - 0
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P.V. Giannoudis et al. / Injury, Int. J. Care Injured 33 (2002) 117–121
2. Patients and methods We reviewed the medical records and radiographs of all the patients treated with surgical decompression of compartment syndrome. Between 1993 and 1998, there were 42 cases. Five patients were lost to follow up, three cases involved the femur (lateral compartment), two cases involved the foot and two had forearm compartment syndrome. The remaining 30 cases comprised a homogenous group of tibial compartment syndrome – patients who underwent fasciotomies. However, one male patient 75 years of age was excluded from the final analysis due to a complex segmental tibial fracture, the only one in this series. In total 29 patients were studied. All the patients underwent fasciotomy within 12 h of injury. All the cases associated with tibial fractures progressed to bone union prior to final review. None of the patients studied suffered from peripheral vascular disease, diabetes or other medical condition that could affect or negatively bias the study outcome. Information was collected on age, sex, mechanism of injury, the measurement or not of intracompartmental pressures, the presence or absence of bone injury, the presence of infection, debridement of muscle tissue and timing of closure of the fasciotomy wounds with or without skin graft. Subsequently, all the patients were recalled for a follow-up assessment during which they were asked to complete an EQ-5D (EuroQol), a standardised measure of health related quality of life [10] as well as to indicate the degree of satisfaction with wound site, and any consequential functional impairment resulting from their injury. Patients studied were compared to a group of randomly selected patients from our database that had sustained isolated closed tibial shaft fractures without developing compartment syndrome. This group of patients who formed the ‘control group’ of this study was also recalled for a follow-up assessment during which the patients were asked to complete an EQ-5D and to indicate any consequential functional impairment resulting from their injury. Applicable to a wide range of health conditions and treatments the EQ-5D provides both a compact descriptive profile and a single index value that can be used in the clinical and economic evaluation of health care. The EQ-5D has been found to be acceptable, valid and reliable in population studies and with other patient groups [11,12]. It consists of five dimensions (mobility, self-care, usual activity, anxiety/depression and pain/discomfort). Each dimension has three levels of statement representing degrees of perceived problem. In addition to the five dimensions, the EQ-5D also incorporates a visual analogue scale (VAS) on which patients are
requested to rate their health on a scale 0 (worst imaginable health) to 100 (best imaginable health). A total of 245 theoretically possible health states can be defined, and weights for these states were derived from a national representative survey of UK population [13,14]. The minimum follow-up time of all the patients was 12 months.
3. Statistical analysis Assumption of normality was tested with a one sample Kolmogorov–Smirnov test. Parametric and non-parametric data were compared, using the unpaired Student’s t test, Mann–Whitney U test and 2 test. Differences were considered significant at PB 0.05.
4. Results There were 25 male and four female patients. The mean age was 35 years (range 19–65). Fourteen cases involved the anterior compartment and 15 all four compartments. The mean follow-up period was 15 months (range 12–25). Road traffic accidents accounted for 18 cases of compartment syndrome, football injuries caused four, direct blows following assaults caused two and the remaining five resulted from falls. Twenty-six cases were associated with a fracture of the tibia. Seven cases were diagnosed postoperatively following intramedullary nailing for stabilisation of tibial fractures. Five patients underwent muscle debridement. Eight patients underwent closure of the fasciotomy wounds with skin grafts. The mean time to wound closure directly or with skin graft was 3.1 days (range 2–7). Three cases (without skin grafts) were complicated by superficial skin infection, which settled with intravenous antibiotics. The control group consisted of 30 patients (23 male and seven female) with a mean age of 39 years (range 18–68). There was no statistically significant difference between the two groups of patients in respects to sex and age (P= 0.1). Eighteen patients had sustained their tibial fractures following road traffic accidents, eight following falls and four due to sport injuries (two rugby, one football, and one horse jumping). All the patients in the control group had their fractures stabilised by early (within 24 h) intramedullary nailing. All the fractures in both group of patients had progressed to union. The mean union time was 23 weeks (range 16–25) and 19 weeks (range 14–21) for the fasciotomy and the control group, respectively. The mean follow-up time for the control group was 16 months (range 12–36).
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 33 (2002) 117–121
4.1. Impact on function Patients who reported an impact on function tended to be older (mean age 42.5 years) than patients without (mean age 27.3 years; P =0.046; Table 1). Patients reporting no impact on function reported no problems on four of the five EQ-5D dimensions, although 25% did report some problem with pain/discomfort. Of patients reporting a residual impact on their function, over 85% indicated a current problem with pain/discomfort (data not shown). The EQ-5D weighted index is significantly higher (better) for those with no impact on function (mean EQ-5D=0.946) than for those reporting impact on function (mean EQ-5D= 0.619; PB 0.001). Self-rated health status was significantly higher (better), in patients reporting no impact on function PB 0.001 (Table 1).
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Table 2 Percentage of patients reporting any problem with and without skin graft Skin graft Yes
P value No
(a) For the self-rated health status and EQ-5D index Number 8 21 Age 41.1 33.6 Self-rated health status 74.1 89.0 EQ-5D index 0.619 0.946 (b) For each of the fi6e EQ-5D dimensions Number 8 21 Mobility 50.0 23.8 Self-care 37.5 9.5 Usual activity 75.0 28.6 Pain/discomfort 87.5 38.1 Anxiety/depression 12.5 9.5 Impact on activity 87.5 28.6
NS 0.034 0.012
NS NS NS 0.017 NS 0.004
4.2. Length of wound closure Two patient groups were identified, fast (3 days or less) and slow (4– 7 days). Patients with faster wound closure tended to have better levels of function (90%) than did patients with slower wound closure (81% of original function; data not shown; this was not statistically significant).
4.3. Skin graft Patients with skin graft tend to be older (P = 0.8) and to rate their own health status as poorer, than patients not having a skin graft. The weighted EQ-5D index and self-rated health status indicates a significantly lower (poorer) score for patients who have had a skin graft PB 0.01 (Table 2(a)). Patients with a graft are also significantly more likely to report pain/discomfort and an impact on activity (Table 2(b)).
4.4. Appearance For the assessment of the impact of appearance to function, two categories of response were used: none or some. Patients with some degree of problem tended to be older than patients reporting no problem with appear-
ance (P= 0.029). Self-rated health status on the VAS ‘thermometer’ was significantly higher for patients reporting no problem with appearance. The weighted EQ-5D index also indicates a highly significant difference between the two patient groups (Table 3). In general patients reporting a problem with their wound appearance seem to have a significant poorer mobility, self-care and pain and discomfort compared to patients that appearance is not a problem (Table 4).
4.5. Comparison with control group Paired comparisons t tests indicated significant differences between the patients and the control group using the weighted index form of the EQ-5D (Table 5). Patients in this study reported more problems on the dimensions of EQ-5D than were reported in the control group, although patients in the control group appear to have a significant higher incidence of anxiety and depression (PB 0.05; Fig. 1). However, between the two groups of patients, their overall self-rated health did not reach significant difference (P= 0.06; Table 5).
Table 3 Appearance of lower limb and the weighted EQ-5D index
Table 1 The impact on function
Appearance Impact on function
Number Age Self-rated health status EQ-5D index
Yes
No
13 42.5 71.9 0.619
16 27.3 95.1 0.946
P value
P value
0.046 B0.001 B0.001
Number Age Self-rated health status EQ-5D index
Not a problem
Some problem
16 29.6 93.5
13 43.2 74.2
0.931
0.631
0.029 0.001 B0.001
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 33 (2002) 117–121
120
Table 4 Percentage of patients reporting any problem on each of the five EQ-5D dimensions Appearance not a problem
Appearance a problem
P value
Mobility 12.5 Self-care 0 Usual activity 12.5 Pain/discomfort 25.0 Anxiety/depression 0
53.8 38.5 76.9 84.6 23.1
0.017 0.006 0.002 0.001 0.042
Impact on activity
84.6
B0.001
12.5
5. Discussion Compartment syndrome is a serious potential complication of trauma to the extremities. Fractures, crush injuries, burns and arterial injuries can result in increased tissue pressure within closed compartmental spaces that may cause irreparable damage to muscle or nerve leading to poor functional result. The World Health Authority defines a number of factors as pivotal in quality of life analysis, these are physical, social and psychological well being [15]. The EuroQol like other available generic instruments analyses all of these dimensions. Eight patients underwent skin grafting and exhibited a poorer long-term outcome when compared to the patients without skin grafting. In particular, out of the five EQ-5D dimensions, the one that reached statistical significance was the dimension of pain and discomfort and the impact on function. This finding may be attributed to the adhesions and scarring that can be developed among the split skin graft and the underlying muscle. In addition this study provides evidence that delayed closure of the wound is also associated with a poorer long-term outcome suggesting that wound closure should take place as soon as possible and any unexpected delays in hospital should be avoided. The early diagnosis and prompt treatment of compartment syndrome by means of fasciotomies should be encouraged and whenever possible closure of wounds without the use of skin grafting. Table 5 Comparison of trauma patients with control group
Control group Patients Difference P value
Self-rated health status
Weighted EQ-5D index
83.7 81.6 2.1 0.06
0.891 0.783 0.108 0.03
Fig. 1. EQ-5D profiles of patients with compartment syndrome in comparison with control group.
The long-term sequelae following compartment syndrome have not been extensively investigated. Vandervelpen et al. [16] assessed the functional outcome of 28 patients on an average of 17 months following tibial fasciotomies. They reported that more than one-fourth of the patients showed late functional disabilities mainly because of limitation of the dorsiflexion of the ankle joint, reduction of the function strength of the foot extensors, contractures of the foot flexors and abnormal superficial sensibility [16]. In another study, the long-term damage of muscle surgically treated for compartment syndrome was evaluated by means of sonography in 27 patients after an average of 98 months (43–154) following trauma. Twelve patients had fasciotomy for a manifest compartment syndrome and 15 for imminent. Comparison of the affected lower limb side to the healthy one, revealed changes of echogenicity reflecting the loss of typical muscle texture in all the patients with manifest compartment syndrome. Only two patients demonstrated sonographic changes in the imminent group [17]. The most striking finding of this study is that patients reporting problems with the appearance of their limb had a significantly increased likelihood of problems with mobility, self-care, anxiety and pain. There can be little argument that poor looking scars can have a negative affect on the outcome of a successful operation. We have also shown that older patients are not necessary more tolerant of poor cosmetic results. This study supports the importance of careful skin closure in order to maximise the outcome of the surgical procedure. We chose a group of patients with closed tibial diaphyseal fractures for the control group in this study as it has been shown that muscle recovery in the lower limbs is affected after diaphyseal tibial fractures [18]. The patients studied following surgical treatment for compartment syndrome demonstrated significantly more problems on the EQ-5D dimensions than were reported in the control group of patients (PB0.05). This finding supports the view that tibial fractures associated with compartment syndrome have a poorer
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 33 (2002) 117–121
outcome compared with isolated tibial shaft fractures. However, when comparing the two group of patients in regards to self-rated health status it does not appear to be a significant difference (P= 0.06). Nonetheless, it is likely that this finding may well represent a type II error due to the small group of patients studied. This study suggests that such symptoms as pain and discomfort as well as poor mobility may be long lasting following surgical treatment of compartment syndrome and provides a benchmark of further long-term and comparative studies. In conclusion, compartment syndrome may be associated with long-term symptoms and a continuing shortfall in patients’ health related quality of life.
References [1] Gershuni CH, Mubarak SJ, Yaru NC, Lee YF. Fracture of the tibia complicated by acute compartment syndrome. Clin Orthop 1987;217:117 – 221. [2] McGee DL, Dalsey WC. The mangled extremity. Compartment syndrome and amputations. Emerg Med Clin N Am 1992;10(4):783 – 800. [3] Mubarak SJ, Hargens AR. Compartment syndromes and Volkmann’s contracture. Philadelphia: WB Saunders, 1981:113. [4] Mabee JR. Compartment syndrome: a complication of acute extremity trauma. J Emerg Med 1994;12(5):651 –6. [5] Rorabeck CH, Macnab I. The pathophysiology of the anterior tibial compartment syndrome. Clin Orthop 1975;113:52.
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[6] Mubarak SJ. A practical approach to compartment syndromes. Part II, diagnosis. Instr Course Lect 1983;32:92 – 102. [7] Mabee JR, Bostwick TL. Pathophysiology and mechanisms of compartment syndrome. Orthopaed Rev 1993;22(2):175 – 81. [8] Tornetta P, Templeman D. Compartment syndrome associated with tibial fracture. Instr Course Lect 1997;46:303 – 8. [9] Ellis H. Disabilities after tibial fractures. J Bone Jt Surg 1958;40B:190 – 7. [10] The Euroqol group. EuroQol: a new facility for measurement of health related quality of life. Hlth Policy 1990;16:199 – 208. [11] Kind P. Measuring health status in community: a comparison of methods. J Epidemiol Commun Hlth 1994;48:86 – 91. [12] Brazier J, Jones N, Kind P. Testing the validity of the EuroQol and comparing it with the SF-36 health survey questionnaire. Qual Life Res 1993;2:169 – 79. [13] Williams A. The measurement and valuation of health: a chronicle. Discussion paper 136. Centre of Health Economics, The University of York, 1995. [14] Kind P, Dolan P, Gudex C, et al. Variations in population health status: results from a United Kingdom national questionnaire survey. Br Med J 1998;316:736 – 41. [15] World Health Organisation. The constitution of WHO. WHO Chronicle 1947;1:29. [16] Vandervelpen G, Goris L, Broos PL, Rommens PM. Functional sequelae in tibial shaft fractures with compartment syndrome following primary treatment with urgent fasciotomy. Acta Chir Belg 1992;92(5):234 – 40. [17] Kullmer K. Traumatically-induced compartment syndrome of the tibia. Ultrasound diagnosis for qualitative assessment of late sequelae for mesculature after dermatofasciotomy. Unfallchirurgie 1997;23(3):87 – 91. [18] Court-Brown CM, Gaston P, McQueen M. Muscle recovery after diaphyseal fracture. In: Proceedings of the 15th Annual Meeting on the Orthopaedic Trauma Association, 1999; p. 180 – 81.
The impact of lower leg compartment syndrome on health related quality of life P.V. Giannoudis a,*, C. Nicolopoulos a, H. Dinopoulos b, A. Ng a, S. Adedapo b, P. Kind c a
Le6el 5, C.S.B., Department of Orthopaedics and Trauma, Uni6ersity of Leeds, St James’s Hospital, Beckett Street, Leeds LS9 7TF, UK b Department of Orthopaedics and Trauma, Bradford Royal Infirmary, Bradford BD9 6RJ, UK c Centre for Health Economics, Uni6ersity of York, York YO1 5DD, UK Accepted 11 May 2001
Abstract Although the aetiology, pathophysiology and treatment of acute compartment syndrome have been well described in the literature, there is limited information on the long-term impact of compartment syndrome on quality of life. We reviewed the medical records and radiographs of all the patients treated with surgical decompression of compartment syndrome. Between 1993 and 1998, 42 cases were identified. There were 30 cases of tibial compartment syndrome and 12 cases involving other limbs. These 30 patients were recalled for a follow-up assessment during which they were asked to complete an EQ-5D (EuroQol), a standardised measure of health related quality of life based on five dimensions (self-care, pain/discomfort, mobility, usual activities and anxiety/depression). Patients were compared with EQ-5D age/sex norms derived from a randomly selected group of patients that had sustained isolated closed tibial shaft fractures. The minimum follow-up time was 12 months. Patients who stated that the appearance of the surgical site was a problem, reported significantly poorer health related quality of life than did patients who had no problem with the appearance. Patients with skin graft reported more problems with pain and discomfort than patients without skin graft. Patients with faster closure times of the wound showed significantly better self-rated health status than patients in whom the wound closure time was longer. Although the patients in this study reported significantly more problems on the dimensions of EQ-5D than were reported in the control group, their overall self-rated health was not statistically different. This study has demonstrated that compartment syndrome may be associated with long-term impact on health related quality of life. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction Acute compartment syndrome of the lower extremity is a condition that requires immediate surgical treatment. The clinical diagnosis may occasionally be obvious but sometimes the findings are not apparent. Failure or delay in reaching the diagnosis of acute compartment syndrome may lead to irreparable damage to muscle or nerve leading to poor long-term function [1,2]. Despite the increased clinical awareness of the condition, it continues to be a significant cause of * Corresponding author. Tel.: + 44-113-2433-144x65222. E-mail address: [email protected] (P.V. Giannoudis).
morbidity among trauma patients [3,4]. Although the aetiology, pathophysiology and treatment of acute compartment syndrome have been well described in the literature [5–8], there is limited knowledge of the longterm impact of compartment syndrome on the quality of life of patients. The incidence of ischaemic contractures as a complication of tibial fractures has been reported to be : 2%, however, the long-term effect of this is not known [9]. Accordingly, we reviewed all the cases of compartment syndrome in our institution in order to assess the long-term outcome as per the quality of life of patients following early decompression of an acute compartment syndrome.
0020-1383/02/$ - see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 0 7 3 - 0
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P.V. Giannoudis et al. / Injury, Int. J. Care Injured 33 (2002) 117–121
2. Patients and methods We reviewed the medical records and radiographs of all the patients treated with surgical decompression of compartment syndrome. Between 1993 and 1998, there were 42 cases. Five patients were lost to follow up, three cases involved the femur (lateral compartment), two cases involved the foot and two had forearm compartment syndrome. The remaining 30 cases comprised a homogenous group of tibial compartment syndrome – patients who underwent fasciotomies. However, one male patient 75 years of age was excluded from the final analysis due to a complex segmental tibial fracture, the only one in this series. In total 29 patients were studied. All the patients underwent fasciotomy within 12 h of injury. All the cases associated with tibial fractures progressed to bone union prior to final review. None of the patients studied suffered from peripheral vascular disease, diabetes or other medical condition that could affect or negatively bias the study outcome. Information was collected on age, sex, mechanism of injury, the measurement or not of intracompartmental pressures, the presence or absence of bone injury, the presence of infection, debridement of muscle tissue and timing of closure of the fasciotomy wounds with or without skin graft. Subsequently, all the patients were recalled for a follow-up assessment during which they were asked to complete an EQ-5D (EuroQol), a standardised measure of health related quality of life [10] as well as to indicate the degree of satisfaction with wound site, and any consequential functional impairment resulting from their injury. Patients studied were compared to a group of randomly selected patients from our database that had sustained isolated closed tibial shaft fractures without developing compartment syndrome. This group of patients who formed the ‘control group’ of this study was also recalled for a follow-up assessment during which the patients were asked to complete an EQ-5D and to indicate any consequential functional impairment resulting from their injury. Applicable to a wide range of health conditions and treatments the EQ-5D provides both a compact descriptive profile and a single index value that can be used in the clinical and economic evaluation of health care. The EQ-5D has been found to be acceptable, valid and reliable in population studies and with other patient groups [11,12]. It consists of five dimensions (mobility, self-care, usual activity, anxiety/depression and pain/discomfort). Each dimension has three levels of statement representing degrees of perceived problem. In addition to the five dimensions, the EQ-5D also incorporates a visual analogue scale (VAS) on which patients are
requested to rate their health on a scale 0 (worst imaginable health) to 100 (best imaginable health). A total of 245 theoretically possible health states can be defined, and weights for these states were derived from a national representative survey of UK population [13,14]. The minimum follow-up time of all the patients was 12 months.
3. Statistical analysis Assumption of normality was tested with a one sample Kolmogorov–Smirnov test. Parametric and non-parametric data were compared, using the unpaired Student’s t test, Mann–Whitney U test and 2 test. Differences were considered significant at PB 0.05.
4. Results There were 25 male and four female patients. The mean age was 35 years (range 19–65). Fourteen cases involved the anterior compartment and 15 all four compartments. The mean follow-up period was 15 months (range 12–25). Road traffic accidents accounted for 18 cases of compartment syndrome, football injuries caused four, direct blows following assaults caused two and the remaining five resulted from falls. Twenty-six cases were associated with a fracture of the tibia. Seven cases were diagnosed postoperatively following intramedullary nailing for stabilisation of tibial fractures. Five patients underwent muscle debridement. Eight patients underwent closure of the fasciotomy wounds with skin grafts. The mean time to wound closure directly or with skin graft was 3.1 days (range 2–7). Three cases (without skin grafts) were complicated by superficial skin infection, which settled with intravenous antibiotics. The control group consisted of 30 patients (23 male and seven female) with a mean age of 39 years (range 18–68). There was no statistically significant difference between the two groups of patients in respects to sex and age (P= 0.1). Eighteen patients had sustained their tibial fractures following road traffic accidents, eight following falls and four due to sport injuries (two rugby, one football, and one horse jumping). All the patients in the control group had their fractures stabilised by early (within 24 h) intramedullary nailing. All the fractures in both group of patients had progressed to union. The mean union time was 23 weeks (range 16–25) and 19 weeks (range 14–21) for the fasciotomy and the control group, respectively. The mean follow-up time for the control group was 16 months (range 12–36).
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 33 (2002) 117–121
4.1. Impact on function Patients who reported an impact on function tended to be older (mean age 42.5 years) than patients without (mean age 27.3 years; P =0.046; Table 1). Patients reporting no impact on function reported no problems on four of the five EQ-5D dimensions, although 25% did report some problem with pain/discomfort. Of patients reporting a residual impact on their function, over 85% indicated a current problem with pain/discomfort (data not shown). The EQ-5D weighted index is significantly higher (better) for those with no impact on function (mean EQ-5D=0.946) than for those reporting impact on function (mean EQ-5D= 0.619; PB 0.001). Self-rated health status was significantly higher (better), in patients reporting no impact on function PB 0.001 (Table 1).
119
Table 2 Percentage of patients reporting any problem with and without skin graft Skin graft Yes
P value No
(a) For the self-rated health status and EQ-5D index Number 8 21 Age 41.1 33.6 Self-rated health status 74.1 89.0 EQ-5D index 0.619 0.946 (b) For each of the fi6e EQ-5D dimensions Number 8 21 Mobility 50.0 23.8 Self-care 37.5 9.5 Usual activity 75.0 28.6 Pain/discomfort 87.5 38.1 Anxiety/depression 12.5 9.5 Impact on activity 87.5 28.6
NS 0.034 0.012
NS NS NS 0.017 NS 0.004
4.2. Length of wound closure Two patient groups were identified, fast (3 days or less) and slow (4– 7 days). Patients with faster wound closure tended to have better levels of function (90%) than did patients with slower wound closure (81% of original function; data not shown; this was not statistically significant).
4.3. Skin graft Patients with skin graft tend to be older (P = 0.8) and to rate their own health status as poorer, than patients not having a skin graft. The weighted EQ-5D index and self-rated health status indicates a significantly lower (poorer) score for patients who have had a skin graft PB 0.01 (Table 2(a)). Patients with a graft are also significantly more likely to report pain/discomfort and an impact on activity (Table 2(b)).
4.4. Appearance For the assessment of the impact of appearance to function, two categories of response were used: none or some. Patients with some degree of problem tended to be older than patients reporting no problem with appear-
ance (P= 0.029). Self-rated health status on the VAS ‘thermometer’ was significantly higher for patients reporting no problem with appearance. The weighted EQ-5D index also indicates a highly significant difference between the two patient groups (Table 3). In general patients reporting a problem with their wound appearance seem to have a significant poorer mobility, self-care and pain and discomfort compared to patients that appearance is not a problem (Table 4).
4.5. Comparison with control group Paired comparisons t tests indicated significant differences between the patients and the control group using the weighted index form of the EQ-5D (Table 5). Patients in this study reported more problems on the dimensions of EQ-5D than were reported in the control group, although patients in the control group appear to have a significant higher incidence of anxiety and depression (PB 0.05; Fig. 1). However, between the two groups of patients, their overall self-rated health did not reach significant difference (P= 0.06; Table 5).
Table 3 Appearance of lower limb and the weighted EQ-5D index
Table 1 The impact on function
Appearance Impact on function
Number Age Self-rated health status EQ-5D index
Yes
No
13 42.5 71.9 0.619
16 27.3 95.1 0.946
P value
P value
0.046 B0.001 B0.001
Number Age Self-rated health status EQ-5D index
Not a problem
Some problem
16 29.6 93.5
13 43.2 74.2
0.931
0.631
0.029 0.001 B0.001
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 33 (2002) 117–121
120
Table 4 Percentage of patients reporting any problem on each of the five EQ-5D dimensions Appearance not a problem
Appearance a problem
P value
Mobility 12.5 Self-care 0 Usual activity 12.5 Pain/discomfort 25.0 Anxiety/depression 0
53.8 38.5 76.9 84.6 23.1
0.017 0.006 0.002 0.001 0.042
Impact on activity
84.6
B0.001
12.5
5. Discussion Compartment syndrome is a serious potential complication of trauma to the extremities. Fractures, crush injuries, burns and arterial injuries can result in increased tissue pressure within closed compartmental spaces that may cause irreparable damage to muscle or nerve leading to poor functional result. The World Health Authority defines a number of factors as pivotal in quality of life analysis, these are physical, social and psychological well being [15]. The EuroQol like other available generic instruments analyses all of these dimensions. Eight patients underwent skin grafting and exhibited a poorer long-term outcome when compared to the patients without skin grafting. In particular, out of the five EQ-5D dimensions, the one that reached statistical significance was the dimension of pain and discomfort and the impact on function. This finding may be attributed to the adhesions and scarring that can be developed among the split skin graft and the underlying muscle. In addition this study provides evidence that delayed closure of the wound is also associated with a poorer long-term outcome suggesting that wound closure should take place as soon as possible and any unexpected delays in hospital should be avoided. The early diagnosis and prompt treatment of compartment syndrome by means of fasciotomies should be encouraged and whenever possible closure of wounds without the use of skin grafting. Table 5 Comparison of trauma patients with control group
Control group Patients Difference P value
Self-rated health status
Weighted EQ-5D index
83.7 81.6 2.1 0.06
0.891 0.783 0.108 0.03
Fig. 1. EQ-5D profiles of patients with compartment syndrome in comparison with control group.
The long-term sequelae following compartment syndrome have not been extensively investigated. Vandervelpen et al. [16] assessed the functional outcome of 28 patients on an average of 17 months following tibial fasciotomies. They reported that more than one-fourth of the patients showed late functional disabilities mainly because of limitation of the dorsiflexion of the ankle joint, reduction of the function strength of the foot extensors, contractures of the foot flexors and abnormal superficial sensibility [16]. In another study, the long-term damage of muscle surgically treated for compartment syndrome was evaluated by means of sonography in 27 patients after an average of 98 months (43–154) following trauma. Twelve patients had fasciotomy for a manifest compartment syndrome and 15 for imminent. Comparison of the affected lower limb side to the healthy one, revealed changes of echogenicity reflecting the loss of typical muscle texture in all the patients with manifest compartment syndrome. Only two patients demonstrated sonographic changes in the imminent group [17]. The most striking finding of this study is that patients reporting problems with the appearance of their limb had a significantly increased likelihood of problems with mobility, self-care, anxiety and pain. There can be little argument that poor looking scars can have a negative affect on the outcome of a successful operation. We have also shown that older patients are not necessary more tolerant of poor cosmetic results. This study supports the importance of careful skin closure in order to maximise the outcome of the surgical procedure. We chose a group of patients with closed tibial diaphyseal fractures for the control group in this study as it has been shown that muscle recovery in the lower limbs is affected after diaphyseal tibial fractures [18]. The patients studied following surgical treatment for compartment syndrome demonstrated significantly more problems on the EQ-5D dimensions than were reported in the control group of patients (PB0.05). This finding supports the view that tibial fractures associated with compartment syndrome have a poorer
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outcome compared with isolated tibial shaft fractures. However, when comparing the two group of patients in regards to self-rated health status it does not appear to be a significant difference (P= 0.06). Nonetheless, it is likely that this finding may well represent a type II error due to the small group of patients studied. This study suggests that such symptoms as pain and discomfort as well as poor mobility may be long lasting following surgical treatment of compartment syndrome and provides a benchmark of further long-term and comparative studies. In conclusion, compartment syndrome may be associated with long-term symptoms and a continuing shortfall in patients’ health related quality of life.
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