Variation in Diagnosis of Compartment Syndrome by Surgeons Treating Tibial Shaft Fractures

Abstract

It is agreed that missed compartment syndrome is associated with significant morbidity, but controversy regarding its diagnosis remains. To our knowledge, no one has analyzed the effect of individual surgeon variation on the diagnosis of compartment syndrome. We analyzed a consecutive cohort of patients with tibial shaft fractures at our level I trauma center (n = 386 fractures). We identified all patients who were diagnosed as having compartment syndrome and who therefore underwent fasciotomy. The surgeon of record for each patient was recorded. Surgeons took call on random nights. All the surgeons were full-time orthopedic trauma surgeons. Patients with "prophylactic" fasciotomies were not included. Results were analyzed by conducting analysis of variance and the Kruskal-Wallis H test. Even though all the surgeons practiced at the same hospital during the same time period, wide variation existed in the rate of diagnosis and treatment of compartment syndrome. The rate ranged from a maximum of 24% to a minimum of 2% of the tibial fractures being diagnosed with compartment syndrome, depending on the surgeon. The differences were highly statistically significant (p < 0.005, Kruskal-Wallis H test). The surgeons' use of compartment pressure checks also varied (p < 0.05, Kruskal-Wallis H test) and seemed to approximately parallel the rate of compartment syndrome diagnosis. The diagnosis of compartment syndrome is difficult, and the data reported herein show that significant practice variation is likely, even within a single institution. It is unknown what the "true" rate of compartment syndrome should be, considering that a rate that is too high indicates unnecessary surgery and a rate that is too low means missing a devastating injury. Our data indicate lack of consensus in practice regarding the diagnosis of compartment syndrome, even at a high-volume level I trauma center, and emphasize the possibility of false-positive results of compartment pressure checks in clinical practice.