Do Widespread or Selective Invasive Monitoring Increase the Rate of Fasciotomies for Tibial Shaft and Plateau Fractures, or Affect the Incidence of Possible Missed Compartment Syndrome?

INTRODUCTION

To report the incidence of lower leg fasciotomies in tibial shaft and plateau fractures and explore the incidence of potential missed acute compartment syndrome (ACS) with widespread, selective, or no invasive monitoring (IM).

METHODS

This is a retrospective review of adult patients with diaphyseal tibial fractures (Orthopaedic Trauma Association 42A-C), and proximal tibial fractures (Orthopaedic Trauma Association 41A-C) treated surgically at a Level 1 trauma center from 2001 to 2020. Main outcomes of interest include lower extremity fasciotomy rates and incidence of potential missed ACS (abnormal neurovascular examination, sensory changes, chronic pain, claw toes, or amputation) in diaphyseal and proximal tibial fractures at three time intervals: widespread use of IM (w-IM) (2000 to 2010), selective IM (s-IM) (2011 to 2015), and clinical examination with a high index of suspicion alone without IM (CES), 2016 to 2020.

RESULTS

Fasciotomy rates decreased from 4.96% (93 in 1,873) in 2001 to 2010 (w-IM) to 2.61% (32 in 1,226) in 2011 to 2015 (s-IM) and to 1.11% (16 in 1,438) in 2016 to 2020 (CES) ( P < 0.001). Random samples of 317 patients with tibial shaft and plateau fractures that did not undergo fasciotomy from 2001 to 2010 (w-IM), 304 patients from 2011 to 2015 (s-IM), and 285 patients from 2016 to 2020 (CES) found that 96.5% had a normal neurovascular examination in the w-IM group, 98.4% in the s-IM group, and 96.8% in the CES group, P = 0.210. No differences were found in sensory changes in the three groups (0.6% for w-IM vs. 1.6% for s-IM vs. 0.4% for CES, P = 0.235) or severe pain (0.6% vs. 0.3% vs. 0.7%, P = 0.589). No patients had late amputation or claw toes in any group. The combined complication rate was slightly lower in the s-IM group (2.0%) and the CES group (2.8%) compared with the w-IM group (4.4%) ( P = 0.214).

CONCLUSIONS

The rate of fasciotomy for ACS in proximal and diaphyseal tibial fractures has declined over time at our center coinciding with the decreased use of IM with no apparent increase in missed ACS.

LEVEL OF EVIDENCE: Diagnostic Level III.