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Predictors of Death and Amputation After Acute Leg Compartment Syndrome

Key findings

  • Death following acute leg compartment syndrome appears to be related to the initial injury burden and the patient's ability to respond to the injury, rather than the burden of local tissue necrosis
  • Risk factors for death were older age, higher modified Charlson Comorbidity Index, higher potassium, higher lactate and lower hemoglobin
  • Risk factors for amputation were diabetes mellitus, no compartment pressure measurement, higher partial thromboplastin time and lower albumin

For patients with acute compartment syndrome, delay in time from injury to fasciotomy has been documented to result in poor outcomes, including irreversible tissue ischemia, neurologic deficits and contractures.

Reporting in the European Journal of Orthopaedic Surgery & Traumatology, Dafang Zhang, MD, of Brigham and Women's Hospital, Neal Chen, MD, chief of the Hand & Arm Center of the Department of Orthopaedic Surgery at Massachusetts General Hospital, and colleagues explain that death and amputation appear to be associated with patient-related and injury-related factors.

Study Design

The researchers studied 546 patients (558 legs) with acute leg compartment syndrome who presented to one of two Level I trauma centers and underwent fasciotomy between January 1, 2000, and June 30, 2015. The outcome of interest was death or limb amputation (either below-knee or above-knee) during inpatient admission.

Time to fasciotomy was classified as less than six hours, six to 24 hours or more than 24 hours. These categories were chosen based on research suggesting that six hours and 24 hours are important thresholds for positive outcomes in acute compartment syndrome.

Characteristics of the Cohort

Sixty-eight percent of patients were male and the average age was 50. The most common mechanisms of injury were high-energy blunt trauma (36%) and vascular injury (33%). Overall, 62% of the cases resulted from trauma.

Forty-one percent of patients underwent fasciotomy within six hours of injury, 27% within six to 24 hours and 33% more than 24 hours later. Late surgery was probably due to gradually evolving nontraumatic processes or the need for transfer to the tertiary referral centers.

Risk Factors for Death or Amputation

6.6% of the patients died during the inpatient admission and 9.5% underwent limb amputation. On multivariable logistic regression analyses:

  • Factors associated with death were older age, higher modified Charlson Comorbidity Index, higher potassium, higher lactate and lower hemoglobin
  • Factors associated with amputation were diabetes mellitus, no compartment pressure measurement, higher partial thromboplastin time and lower albumin

Compartment pressure measurement was performed less frequently in the initial evaluation of patients who eventually underwent amputation than in those who did not (12% vs. 36%; P < .001). This is most likely when patients have fulminant symptoms; compartment pressure measurements are not needed to secure the diagnosis.

Applying the Results to Practice

Patients with acute compartment syndrome who have a severe local injury, diabetes mellitus or hypoalbuminemia should be advised that they are at increased risk of in-hospital limb amputation. Older patients with medical comorbidities, high potassium, high lactate or low hemoglobin are at increased risk of in-hospital mortality. Fasciotomy should be performed as soon as possible in acute leg compartment syndrome.

Learn more about the Hand & Arm Center at Mass General

Refer a patient to the Department of Orthopaedics at Mass General

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