Low compartment pressure and myoglobin levels in tibial fractures with suspected acute compartment syndrome

Abstract

BackgroundThe intense ischemic pain of acute compartment syndrome can be difficult to discriminate from the pain related to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is often only based on clinical findings and performed at a low threshold. Biomarkers of muscle cell damage might help to identify and monitor patients at risk. In patients with fractures, however, markers of muscle cell damage could be elevated because of other reasons associated with the trauma, which would make interpretation difficult. In a review of all patients who underwent emergency fasciotomy in our health care district we aimed to investigate the decision-making process and specifically the use of biomarkers in patients with and without fractures.MethodsIn the southeast health care region of Sweden 79 patients (60 men) with fractures (median age 26 years) and 42 patients (34 men) without associated fractures (median age 44 years) were treated with emergency fasciotomy of the lower leg between 2007 and 2016. Differences in clinical findings, p-myoglobin and p-creatine phosphokinase as well as pressure measurements were investigated.ResultsP-myoglobin was analyzed preoperatively in 20% of all cases and p-creatine phosphokinase in 8%. Preoperative levels of p-myoglobin were lower in patients with fractures (median 1065 μg/L, range 200–3700 μg/L) compared with those without fractures (median 7450 μg/L, range 29–31,000 μg/L), p < 0.05. Preoperative intracompartmental pressure was lower in the fracture group (median 45 mmHg, range 25–90 mmHg) compared with those without fractures (median 83 mmHg, range 18–130 mmHg), p < 0.05.ConclusionsBiomarkers are seldom used in the context of acute fasciotomy of the lower leg. Contrary to our expectations, preoperative levels of p-myoglobin and intracompartmental pressures were lower in fracture patients. These findings support differences in the underlying pathomechanism between the groups and indicate that biomarkers of muscle cell necrosis might play a more important role in the diagnosis of acute compartment syndrome than previously thought.

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“…Blood CK level was significantly higher in the SSI group compared to the non-SSI group. Previous studies have shown that blood CK level may be a marker in diagnosing ACS and evaluating muscle necrosis [ 30 , 31 ]. However, no study shows an association between blood CK levels and SSI.…”

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“…We have recently shown that high intramuscular pressure coincides with high P-myoglobin levels and that myoglobin may be a relevant, yet unexplored diagnostic tool in ACS associated with trauma. 21 …”

Is the Presence of a Psychiatric Disorder Associated With More Aggressive Management of Compartment Syndrome?

“…The diagnosis of ACS in the nonobtunded patient is usually made clinically because measurement of compartment pressures with a Stryker (STIC) needle is an invasive, painful procedure that is less than 100% sensitive for detecting ACS. [1][2][3] Recent work performed by Schmidt et al 4 has shown that no value of perfusion pressure from 10 to 30 mm Hg demonstrates the necessary specificity to accurately diagnose compartment syndrome, further calling into question its use as a primary diagnostic measure. Pain with passive stretch, especially pain that is out of proportion to visible injuries, is the ultimate harbinger of ACS.…”