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Clinical Characteristics of Patients Undergoing Upper Extremity Fasciotomies for Compartment Syndrome at a Level 1 Trauma Center
Stephanie H Vu, BS, Brandon J De Ruiter, MD, Samantha King, MD, Christopher Crowe, MD; Yusha K Liu, MD PhD
University of Washington, Seattle, WA
Introduction:
Early diagnosis and surgical treatment of compartment syndrome are critical to decrease the risk of permanent injury. Despite the incidence of compartment syndrome, there is no consensus on the optimal surgical approach and independent risk factors for muscle necrosis and amputation have not been clearly identified. This study aims to characterize outcomes of upper extremity (UE) fasciotomies to guide surgical decision making.
Materials & Methods:A 14-year retrospective review (2010-2024) of adult patients who underwent UE fasciotomies for compartment syndrome at a level I trauma center was performed. Exclusion criteria included age <18 years, incomplete records, or fasciotomies for other indications. Demographic data, injury mechanism, diagnostic features, intraoperative technique/findings, and need for subsequent amputation was collected by chart review.
Results:
A total of 55 patients (58 extremities) were included in the study (median age: 42 years, 82.8% male). Injury mechanisms were varied and included fractures (29%), found-down (26%), vascular injury (14%), and ballistic trauma (7%). Diagnosis was made by clinical exam alone in the majority of cases (86%) and with needle compartment pressure measurement in those who could not participate with exam (14%). The most common symptom was pain with passive motion/out-of-proportion to exam (72%), followed by paresthesias (48%), paralysis (43%), pulselessness (10%), and pallor (5%). Muscle necrosis was present in 19% of cases and was significantly associated with pallor (p=0.047), pulselessness (p=0.0003), and "found-down" mechanism (p=0.02); while those with fractures had a lesser incidence of muscle necrosis (p<0.001). Fasciotomy incisions included volar forearm (41%), dorsal forearm (5%), hand (8%), and combinations thereof. Among 38 patients with volar forearm fasciotomy incisions alone, none developed dorsal forearm muscle necrosis postoperatively. Patients underwent an average of 3.2 operations (SD 1.8), including debridement and closure (range: 1-9). The average interval between fasciotomy and closure was 12 days (range 0-245). Closure methods included delayed primary closure (DPC 62%), skin grafting (24%), secondary intention (3%), flap coverage (3%), and amputation (7%). Among DPC cases, 21.6% achieved closure at first return to OR. Fractures correlated with higher rates of DPC (p=0.0001). Conversely, "found-down" cases had a lower rate of DPC (p=0.11), and higher rate of amputation (p=0.0003).
Conclusions:
While commonly taught, classic features of compartment syndrome are not always present. Pallor, pulselessness, and found down mechanism were correlated with muscle necrosis and/or amputation. Those with fracture-related mechanisms were more likely to undergo DPC and more likely to have viable muscle.
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