Management and Outcomes of Upper Extremity Compartment Syndrome Transfers from the Community
April Hou, MD1; Aparajit Naram, MD, FACS1; Rachel Lister, MD candidate2; Aixa Perez Coulter, MS, MPH1
1UMass Chan Baystate Medical Center, Springfield, MA; 2UMass Chan Medical School, Worcester, MA
INTRODUCTION: Compartment syndrome is a surgical emergency that requires timely intervention to limit long-term morbidity. Ideal time to decompressive fasciotomy is largely considered to be within eight hours of symptom onset. Given the emergent nature of this pathology, we argue that compartment syndrome is a contraindication for transfer when diagnosed in a facility with surgical capabilities. Lower extremity fasciotomies are performed by Trauma, Vascular, and Orthopedic surgeons alike. Fasciotomies of the forearm and hand, however, while technically simple, are often referred to Hand surgeons, with other providers feeling inexperienced in their diagnosis and management. As a result, patients presenting with upper extremity compartment syndrome in the community are often transferred to a tertiary center for emergent sub-specialty consultation and treatment. These transfers may result in delays in time-sensitive intervention.
MATERIALS & METHODS: A retrospective review was performed on all patients aged 18 and over who were treated for upper extremity compartment syndrome at our institution and referring hospitals from January 1, 2005 to December 31, 2021. These data include information about the referring hospital surgical capabilities, the nature of the initial evaluation performed, and timing from symptoms to surgical decompression. We collected demographics data as well as outcomes data on overall morbidity following treatment.
RESULTS: We identified 94 patients treated for compartment syndrome at our institution, of which 35 patients were transferred from an outside hospital. The most common underlying etiologies were prolonged dependent position (25.6%) and infection (21.4%). Other mechanisms included crush injury, blunt trauma, bleeding, and infiltration. Compartment pressures were checked on 2 patients prior to transfer (5.7%), compared to 12 non-transfer patients (20.3%). The median time between symptom start and surgical decompression for patients who were transferred was 18.8 hours. Only 27% of patients underwent surgery within 8 hours of symptom onset, and 51.9% of transfer patients had profound disability on follow-up.
CONCLUSIONS: Patients transferred from outside institutions experienced a clinically significant delay in management with surgical decompression. The majority of these patients also suffered residual disability of the affected limb. Additionally, many of the transfers occurred over concern for compartment syndrome but not an objective diagnosis, as demonstrated by the infrequent measurement of compartment pressures. Understanding the reasons for transfer within our community is the first step to developing interventions and education to improve diagnostic accuracy and expedite treatment that could potentially eliminate detrimental transfers of care.
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