Compartment syndrome can be a tragedy if not timely diagnosed.
| The Journal of Bone and Joint Surgery (American). 2010;92:361-367.
© 2010 The Journal of Bone and Joint Surgery, Inc.
Physicians’ Ability to Manually Detect Isolated Elevations in Leg Intracompartmental PressureFranklin D. Shuler, MD, PhD1 and Matthew J. Dietz, MD1
1 Department of Orthopaedics, West Virginia University, P.O. Box 9196, Health Sciences Center, Morgantown, WV 26506-9196. E-mail address for M.J. Dietz: [email protected]
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Stryker Corporation, Kalamazoo, Michigan. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
Background Serial physical examination is recommended for patients for whom there is a high index of suspicion for compartment syndrome. This examination is more difficult when performed on an obtunded patient and relies on the sensitivity of manual palpation to detect compartment firmness—a direct manifestation of increased intracompartmental pressure. This study was performed to establish the sensitivity of manual palpation for detecting critical pressure elevations in the leg compartments most frequently involved in clinical compartment syndrome.
Methods Reproducible, sustained elevation of intracompartmental pressure was established in fresh cadaver leg specimens. Pressures tested included 20 and 40 mm Hg (negative controls) and 60 and 80 mm Hg (considered to be consistent with a compartment syndrome). Each leg served as an internal control, with three compartments having a noncritical pressure elevation. Orthopaedic residents and faculty were individually invited to manually palpate the leg with a known compartment pressure and to answer the following questions: (1) Is there a compartment syndrome? (2) In which compartment or compartments do you believe the pressure is elevated, if at all? (3) Describe your examination findings as soft, compressible, or firm.
Results When a true-positive result was considered to be the correct detection of an elevation of intracompartmental pressures and correct identification of the compartment with the elevated pressure, the sensitivity of manual palpation was 24%, the specificity was 55%, the positive predictive value was 19%, and the negative predictive value was 63%. With increasing intracompartmental pressure, fasciotomy was recommended with a higher frequency (19% when the pressure was 20 mm Hg, 28% when it was 40 mm Hg, 50% when it was 60 mm Hg, and 60% when it was 80 mm Hg). When a true-positive result of manual palpation was considered to be an appropriate recommendation of fasciotomy, regardless of the ability of the examiner to correctly localize the compartment with the critical pressure elevation, the sensitivity was 54%, the specificity was 76%, the positive predictive value was 70%, and the negative predictive value was 63%.
Conclusions Manual detection of compartment firmness associated with critical elevations in intracompartmental pressure is poor.