Clinical symptoms with varying combinations and severity in sequential examinations set difficulties in the diagnosis of this ALCS, especially in multi-traumatized patients which diverts clinicians attention, even among expert surgeons. So, high degree of suspicion is essential in addition to adequate knowledge and practical exposure to manage these patients to avoid significant morbidity even mortality and also medico-legal issues, due to delayed or missed diagnosis. Unfortunately, there are variations in perception of basic principles and management of ALCS by orthopedic surgeons clinical practice. Also there is little consensus among authors about appropriate management of ALCS, especially regarding the optimal fasciotomy indication particularly with poly-traumatized and unconscious patients. A recent study showed that incidence of fasciotomy and varied from 2 to 24% highlighting the variability of surgical indications and inconsistency in clinical diagnosis 4,5
. In the survey completed within this study, in case of ALCS, its been aimed to question basic approach to ALCS.
In this study, 54.8% of participants come across ALCS on the crural region and 37.7% of which on the forearm and carpal region most frequently. When we look at literature, tibia shaft fractures are being reported to be responsible for the one-third of all of the ACLS, one-quarter of blunt and crushed soft tissue traumas, and one-fifth of radial and ulnar fractures 6. Also we should keep in mind that, up to 30% of ALCS cases occurs without any evidence of fracture 2,7.
In the survey results, most significant symptom of the ALCS has come out as pain in 74% and the earliest symptom as pain again in 82.2 %. ALCS is a dynamic process in which symptoms evolve progressively. So, examinations should be done serially more over a period of time unless its strongly suspected at initial presentation 6,8. The aim must be to diagnose early enough to intervene progression towards irreversible changes. The classically mentioned the five P signs have low sensitivity but high specificity for diagnosis according to systematic review and combination of these signs might increase the sensitivity 9. But the cardinal symptom for ALCS in conscious patients is pain out of proportion to known injury and doesnt improve with adequate analgesia 6,10. Also pain at rest and with passive stretch is almost always found in evolving ALCS. Moreover, pain can be absent in regional anesthetized patients and sedated patients in ICU 6. Paresthesia is another early sign indicates early nerve ischemia which is followed by hypoesthesia, anesthesia 6,10. Paresis and paralysis are late symptoms which indicate muscular and/or neural lesions 4,6.
Response of participants about the riskiest scenario for displaced comminuted forearm fracture, comminuted tibia shaft fracture, prolonged crush injury and reperfusion after prolonged limb ischemia was 8.9%, 29.5%, 29.5% and 32.3% respectively. This question of survey was purposed to evaluate perceptions of participants about which case scenario is more prone to develop ALCS. According to clinical practice guidelines, a particularly high index of suspicion is necessary for the patient groups as; males aged <35 years with fracture tibia and/or the radius/ulna 11,12, high-energy injuries such as open fractures and/or severe soft tissue injuries 13, patients <35 years with a bleeding disorder or an anticoagulant with soft tissue injuries 14,15 and crush injuries. Despite distribution of participants responses are also probably related to their past experiences, selecting the riskiest situations as reperfusion injury in 32% of the respondents suggest that the situation is not fully understood. Revascularization after acute arterial injury or obstruction can result in ALCS and most of the patients need fasciotomy after revascularization 16.
26.7% of participants express that extremity thats being followed with a diagnosis of compartment syndrome should be kept at higher level than heart level, whereas 62.3% believe that it is better to follow up extremity at a higher level than heart level and/or with cold application. Authors reported that although limb elevation decreased compartment pressure, blood pressure to elevated limb also decreased, resulting in an overall reduction in perfusion pressure 17,18 Also according to clinical practice guidelines, affected limbs should be positioned at heart level in patients at high risk of developing ALCS 19. Moreover, the guidelines recommend patient should be kept in normotensive and high flow of oxygen should be administered if oxygen saturation is suboptimal 19.
In a diagnostic ALCS approach to conscious patients, 59.6% of participants report that severe rest pain and severe pain after passive stretch enough to make a diagnosis. According to clinical practice guidelines, ALCS should be diagnosed in presence of clinical signs especially with pain out of proportion, as cardinal sign. But in alert, high risk patients with equivocal clinical findings, compartment pressure should be measured. Furthermore, in the initial absence of clinical signs, alert, high-risk patients should be assessed for clinical signs of ALCS at least every 4 hour for a minimum of 24 hour after precipitating injury 19. As 8.9% of participants expressed, waiting for 5P symptoms and paresis/paralysis developing secondary to neural and/or muscular damage, means late symptoms are to be observed which result in malpractice 19. Supporting clinical diagnosis with compartment pressure measurement could be acceptable to eliminate possible risk of over/under treatment and as result of medico legal reaction, if and only if there would be no loss of time. Rarely reported literature about ALCS in awake and conscious patients without severe pain also cause confusion 20. However, insistence on making follow-up measurements regardless of clinical findings and meaningful high compartment pressure values might result in delay in diagnosis and treatment, accompanied by malpractice.
In a diagnostic approach to unconscious patients, 22.6% of participants report that compartment pressure should definitely be measured, 11.0% thinks that regardless of meaningfully high compartment pressure values, follow-up measurements should definitely be conducted, 59.6% suggests that compartment pressure measurement might not be completed and fasciotomy is sufficient in case of a clinical suspicion, and 6.8% reports that additional to clinical findings and compartment pressure measurements, Doppler USG should be applied. According to clinical practice guidelines, in unconscious patients, ACLS should be diagnosed in the presence of raised compartment pressure. Furthermore, in initial absence of raised pressure, unconscious, high risk patients should have their compartment pressure measured at least every 4 h for a minimum of 24 h after precipitating injury 19. In an unconscious patient, as majority of clinical signs are subjective, the unproportioned pain to injury and pain not relieved by analgesics which are accepted as the cardinal symptoms of ALCS, are nearly impossible to evaluate. Therefore, as 59.6% of attendees have responded, rather than making a diagnosis of ACLS based on clinical findings, in unconscious and uncooperative patients, diagnosis should be made according to compartment pressure measurements 19. In survey, 33.6% of participants point out that diagnosis should be made according to compartment pressure measurement, while one-third of prementioned amount of participants also suggest that follow-up measurements should be completed, even though there would be meaningful high values of compartment pressures and this reveals the fact that there is confusion in this matter. 6.2% of the responses point out that in addition to clinical findings and compartment pressure measurements, Doppler USG should be used. In literature, there are studies regarding the diagnosis of ALCS through laser Doppler flowmeter. However, this doesnt have a routine use in ALCS diagnosis.
Stryker pressure monitor system, Synthes hand-held compartment pressure monitor, arterial line manometer and Whitesides infusion techniques are methods for measuring compartment pressure 6. More accurate diagnosis is reported with arterial line manometer followed by Stryker device 21. Diversely, Whitesides method gave less accurate results in more than one study. But Whiteside method is lifesaving method if other equipment is unavailable, which consists of simply by intravenous tubing, a three-way stopcock, a syringe and a mercury manometer 22. In our survey, 10.3% of participants reported they have used manometer within their clinics in ALCS-suspicious case; 5.5% have used trademark pressure measurement systems and 4.8% have used manually constructed mechanism. In literature, in two surveys, one dates back to 1998 in the UK 23 and the other one dates back to 2015 in Australia 24, completed regarding ALCS approach, 15% of respondents in study of Williams et al. in UK, compared with 78% in the Wall et al study in Australia routinely used compartment pressure measurement. In our study, only 10.3 % of participants reported they have used manometers in ALCS-suspicious cases and this result is relatively lower than results of other studies conducted. This reveals the fact that medical doctors in our study have an approach to ALCS rather based on clinical experience. However, this might create a risk of missing compartment syndromes especially in unconscious and uncooperative patients 6. The survey, it has been questioned whether or not participants have come across previously missing compartment syndrome. 25.3% of participants reported that they have never come across any previously missing compartment syndrome, 62.4% reported that they have come across 1-3 times, 12.4% reported to have met more than 4 times. Also, in a question, in which participants could choose more than one answers, 32. 2% of the participants have reported that they have not seen manually constructed mechanism, 19.2% neither have seen the mechanism nor have sufficient knowledge to construct the mechanism, 4.1% of which have neither seen nor constructed the mechanism, however, have sufficient knowledge to construct the mechanism. All in all, it has been found out that 55.5% of the participants have not seen manually constructed mechanism before. In addition to this, it has been understood that only 32.8% of the participants have sufficient knowledge to construct the mechanism, whereas 7.5% of which have never constructed the mechanism.
In another question, in which participants general approach to fasciotomy has been questioned, it has been found that 13.7% of participants had an opinion of subcutaneous fasciotomies made through short skin incisions are enough. Skin has been shown to act as a limiting boundary even after a fasciotomy has been performed, that jeopardize limb 15,19,24. So, long skin incisions with full-length fasciotomies are recommended.
In our survey, following controversial subjects are not being questioned; which values should be used, absolute pressure threshold or differential pressure threshold and which values are accepted as cut-off values for fasciotomy, because our real aim has been questioning basic approach to ALCS cases. Therefore, as the questionnaire has been prepared it has been tried to put more emphasis on questions regarding the basic key points in individuals own practices rather than detailed and tiring theoretical information. As responses reveal, orthopedists do still have some confusions about their approach to ALCS cases. This might put a medical doctor in a guilty position in medico-legal means. It is important to make a reminder that in literature there are two studies, analyzing the accusations come up after ALCS and in more than half of cases, decisions have been made against medical doctors 25,26.