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

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 26years) and 42 patients (34 men) without associated fractures (median age 44years) 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 1065g/L, range 200-3700g/L) compared with those without fractures (median 7450g/L, range 29-31,000g/L), p<0.05. Preoperative intracompartmental pressure was lower in the fracture group (median 45mmHg, range 25-90mmHg) compared with those without fractures (median 83mmHg, range 18-130mmHg), 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.