A.Zenelaj, M.Brati, *V.Zenelaj

COMPARTMENT SYNDROME AND ITS TREATMENT IN ARTERIAL TRAUMA

Department of Surgery. Central Military University Hospital.
*Department of General Medicine.”Mother Teresa” University Hospital.
Tirana/Albania.

Introduction:

Trauma is one of major causes of death in our hospital. The patients generally belong the age till fourth decade of life . They had penetrated and blunt vascular trauma injuries. In developed countries the causes of injury usually are road accidents and invasive diagnostic and therapeutic procedures [20,21,22] .

In our hospital in 92 % of patients the injury is been due to aggression of the person ; 5 % are due to road accidents and 3 % iatrogenic ones . Most of the patients have been injured by military weapons , which have high kinetic energy causing massive damage of tissues [17,18,19] . In all cases that a major vascular injury is present the surgical team should be alert of compartment syndrome [2,3,11] .

Material and Methods:

We studied 77 patients with vascular limb injuries during August 1999 – March 2005 .In the study are included patients with major vascular injuries of the limbs and are excluded those with not important vascular injuries . In other words those with injuries that do not threaten the limb viability .

In our cases 72 were males , 5 females . The age of patients rated 13 - 65 years old [ medium 28,9 years old ] . In 62 patients the injury is been in inferior limbs and 15 in superior ones .

The cause of injury was [Graphic 1]:

a - 54 cases by shot guns.

b - 17 cases by sharp weapons.

c - 4 cases by road accidents.

d - 2 cases iatrogenic injuries.

We performed fasciotomy in 29 cases. All of them belong to inferior limbs. Fasciotomy was done when compartment syndrome was installed [1, 3,4]. 33 patients were treated without fasciotomy[8] , 5 of them were complex trauma.

In the cases where fasciotomy was done the injury belonged to the artery alone [ 2 cases ] ; artery and vein [ 20 cases ] ; vascular injury and fracture [ 7 cases ] .

The study has a retrospective analytic character .We compared:

1 – The final result.

2 – Complications.

3 – Complexity.

4 – Duration of stay in hospital.

The statistical test used is of Mann – Whitney.

Results:

An important component in vascular trauma is the complexity of injury [15,16] . In 38 , 9 % of our cases the injury belonged the arterial system . In 61, 1 % there was combined injuries. From them 72 , 3 % was injured the arterial and venous systems . In 21, 3 % there was an artery and a bone fracture. In 6 , 4 % the injury belonged to arterial and muscle –skeletal systems [See graphic 2] .

If we will evaluate cases treated with and without fasciotomy we ’ ll see that cases treated with fasciotomy stayed longer in hospital than those treated without. From the other side if will compare the arrival hospital time , the complexity of injury and the kind of surgical procedure performed , the definition will come that in cases treated with fasciotomy were more complex , they reached late in the trained medical centre and in 85 % of revascularization surgical intervention was performed [See Graphic 2] .

In the cases where fasciotomy is been done our surgical choice was lateral and medial fasciotomy with long incisions [9,10,11] [See Figures 1 and 2] .

In the table 1 there are indicated results in both groups . With not favorable result we considered each case were any kind of amputation was performed .

In all cases with a muscle necrosis , the first signs of ischemia and necrosis appeared in the anterior muscle compartment of lower limbs . In one of the amputated case the revascularization procedure was done 14 hours after the event . In other 3 cases the amputation is performed after fasciotomy was done . Fasciotomy closure was done in a period of time varied 5 - 40 days . This happened due to degree of infection and muscle necrosis .

The median hospital stay for patients treated with fasciotomy was 19 days . In the other group the median hospital stay was 10 days .

Discussion:

We used Mann - Whitney statistical test. Based on the test there was a significant difference [ p < 0.05 ] belonging the complexity of trauma in the fasciotomy and without fasciotomy groups .

There by the amputation rate in the fasciotomy group should have been statistically significant . In fact it resulted that the amputation rate between both groups was comparable .

Also significant difference was between groups belonging duration of stay in hospital . We saw that in the amputated cases there were complex injuries , the arrival time in hospital was late [ 20 - 36 hours ] , surgical procedure was ligature of the artery .

In the results optic we think that fasciotomy is very important in the cases where it is indicated , independently from the fact it usually is followed by longer hospital stay [12,13,14] .

According to muscle necrosis and neuropathy we believe that they are not complications of fasciotomy procedure , but results of delay in performing fasciotomy.

Conclusions:

1 – Fasciotomy is as well important as the revascularization procedure is , making it more effective and reducing sequels of compartment syndrome .

2 - Time , complexity and anatomic region that a peripheral arterial trauma is associated , are important predictor factors in the development of compartment syndrome .

3 - When compartment syndrome is installed long incisions should be done .

4 - The possibility of development of compartment syndrome in upper limbs is less than in the inferior ones.

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