Skip to main content

Advertisement

SpringerLink
Log in

Increased morphine requirements are predictive of acute compartment syndrome in adults with tibia fractures

  • Original Paper
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Purpose

The purpose of this study was to determine if increased milligram morphine equivalent (MME) requirements are a predictor of adult compartment syndrome in patients with tibia fractures.

Methods

A retrospective case-control study at a level-1 trauma center was performed over a five year period. Patients with tibia fractures who had acute compartment syndrome (ACS) requiring fasciotomy (n = 26) were matched with controls (n = 25). MME and pain scores were assessed within the 24 hour period preceding fasciotomy (cases) or fixation (controls). The presence or absence of the “6 Ps” and other clinical signs (diastolic blood pressure [DBP]) were also analyzed.

Results

Mean MMEs two hours before surgery was 25.5 ± 39.2 for ACS patients versus 8.6 ± 11.1 in controls (P = 0.043), while the mean pain scores were 8.8 ± 1.8 and 7.0 ± 2.5 (P = 0.049), respectively. Multivariable regression showed patients with ACS consumed 16.9 MME more than controls within two hours of surgery (P = 0.043) and scored 1.8 points higher on the numeric pain rating scale (P = 0.049). The mean number of clinical signs of compartment syndrome in the ACS patients was 3.4 ± 1.3 compared to 0.84 ± 0.85 in controls (P < 0.001). DBP was significantly higher in ACS patients within two to four hours of surgery (P = 0.005).

Conclusion

Increased MME requirements and pain scores within two hours of surgery were significant predictors of ACS following tibia fracture. Increased narcotic requirements, pain scores, and DBP may be useful objective indicators of evolving ACS, in addition to the traditional signs, and should be closely monitored in the at-risk patient.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Prasarn ML, Ouellette EA (2011) Acute compartment syndrome of the upper extremity. J Am Acad Orthop Surg 19(1):49–58

    Article  Google Scholar 

  2. Zhang D, Tarabochia M, Janssen SJ, Ring D, Chen N (2019) Acute compartment syndrome in patients undergoing fasciotomy of the forearm and the leg. Int Orthop 43(6):1465–1472. https://doi.org/10.1007/s00264-018-4060-2

    Article  PubMed  Google Scholar 

  3. von Keudell AG, Weaver MJ, Appelton PT, Bae DS, Dyer GS, Heng M, Jupiter JB, Vrahas MS (2015) Diagnosis and treatment of acute extremity compartment syndrome. Lancet 386(10000):1299–1310. https://doi.org/10.1016/S0140-6736(15)00277-9

    Article  Google Scholar 

  4. McQueen MM, Court-Brown CM (2010) Early diagnosis of compartment syndrome: continuous pressure measurement or not? Injury 41(4):431–432; author reply 432-433. https://doi.org/10.1016/j.injury.2009.09.031

    Article  CAS  PubMed  Google Scholar 

  5. Olson SA, Glasgow RR (2005) Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 13(7):436–444

    Article  Google Scholar 

  6. Elliott KG, Johnstone AJ (2003) Diagnosing acute compartment syndrome. J Bone Joint Surg (Br) 85(5):625–632

    Article  Google Scholar 

  7. Matsen FA, Winquist RA, Krugmire RB (1980) Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am 62(2):286–291

    Article  Google Scholar 

  8. Sheridan GW, Matsen FA (1976) Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am 58(1):112–115

    Article  CAS  Google Scholar 

  9. Bhattacharyya T, Vrahas MS (2004) The medical-legal aspects of compartment syndrome. J Bone Joint Surg Am 86-A(4):864–868

    Article  Google Scholar 

  10. McQueen MM, Gaston P, Court-Brown CM (2000) Acute compartment syndrome. Who is at risk? J Bone Joint Surg (Br) 82(2):200–203

    Article  CAS  Google Scholar 

  11. McMillan TE, Gardner WT, Schmidt AH, Johnstone AJ (2019) Diagnosing acute compartment syndrome-where have we got to? Int Orthop 43(11):2429–2435. https://doi.org/10.1007/s00264-019-04386-y

    Article  PubMed  PubMed Central  Google Scholar 

  12. Whitesides TE, Heckman MM (1996) Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg 4(4):209–218

    Article  CAS  Google Scholar 

  13. Bae DS, Kadiyala RK, Waters PM (2001) Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop 21(5):680–688

    CAS  PubMed  Google Scholar 

  14. Bendall JC, Simpson PM, Middleton PM (2011) Prehospital vital signs can predict pain severity: analysis using ordinal logistic regression. Eur J Emerg Med 18(6):334–339. https://doi.org/10.1097/MEJ.0b013e328344fdf2

    Article  PubMed  Google Scholar 

  15. Tousignant-Laflamme Y, Rainville P, Marchand S (2005) Establishing a link between heart rate and pain in healthy subjects: a gender effect. J Pain 6(6):341–347. https://doi.org/10.1016/j.jpain.2005.01.351

    Article  PubMed  Google Scholar 

  16. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, Initiative S (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61(4):344–349. https://doi.org/10.1016/j.jclinepi.2007.11.008

    Article  Google Scholar 

  17. McQueen MM, Duckworth AD, Aitken SA, Sharma RA, Court-Brown CM (2015) Predictors of compartment syndrome after tibial fracture. J Orthop Trauma 29(10):451–455. https://doi.org/10.1097/BOT.0000000000000347

    Article  PubMed  Google Scholar 

  18. Ali S, Chambers AL, Johnson DW, Craig WR, Newton AS, Vandermeer B, Curtis SJ (2014) Paediatric pain management practice and policies across Alberta emergency departments. Paediatr Child Health 19(4):190–194

    Article  Google Scholar 

  19. Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P (2003) Emergency department analgesia for fracture pain. Ann Emerg Med 42(2):197–205. https://doi.org/10.1067/mem.2003.275

    Article  PubMed  Google Scholar 

  20. Halpern AA, Nagel DA (1980) Anterior compartment pressures in patients with tibial fractures. J Trauma 20(9):786–790

    Article  CAS  Google Scholar 

  21. Rorabeck CH, Macnab L (1976) Anterior tibial-compartment syndrome complicating fractures of the shaft of the tibia. J Bone Joint Surg Am 58(4):549–550

    Article  CAS  Google Scholar 

  22. Ulmer T (2002) The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma 16(8):572–577

    Article  Google Scholar 

  23. Gelberman RH, Szabo RM, Williamson RV, Hargens AR, Yaru NC, Minteer-Convery MA (1983) Tissue pressure threshold for peripheral nerve viability. Clin Orthop Relat Res 178:285–291

    Google Scholar 

  24. Szabo RM, Gelberman RH, Williamson RV, Hargens AR (1983) Effects of increased systemic blood pressure on the tissue fluid pressure threshold of peripheral nerve. J Orthop Res 1(2):172–178. https://doi.org/10.1002/jor.1100010208

    Article  CAS  PubMed  Google Scholar 

  25. Kakar S, Firoozabadi R, McKean J, Tornetta P 3rd (2007) Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome. J Orthop Trauma 21(2):99–103. https://doi.org/10.1097/BOT.0b013e318032c4f4

    Article  PubMed  Google Scholar 

  26. Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim NA (1986) Compartment syndrome in open tibial fractures. J Bone Joint Surg Am 68(9):1348–1353

    Article  CAS  Google Scholar 

  27. Zweifach SS, Hargens AR, Evans KL, Smith RK, Mubarak SJ, Akeson WH (1980) Skeletal muscle necrosis in pressurized compartments associated with hemorrhagic hypotension. J Trauma 20(11):941–947

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedics, University of Maryland School of Medicine, One Texas Station Court, Suite #300, Baltimore, MD, 21093, USA

    Michael Schloss, Tristan B. Weir, Julio J. Jauregui, Ehsan Jazini & Joshua M. Abzug

Authors
  1. Michael Schloss
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tristan B. Weir
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Julio J. Jauregui
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ehsan Jazini
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joshua M. Abzug
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Joshua M. Abzug.

Ethics declarations

The authors declare that they have no conflict of interest.

Disclaimer

The views expressed in the submitted article are our own and not an official position of the institution.

IRB approval

Approval was obtained from our institutional review board.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendices

Appendix 1

Table 4 Multivariable Linear Regression for Predictors of Acute Compartment Syndrome within Two Hours of Surgery
Full size table

Appendix 2

Table 5 Vital Signs for Patients With and Without Acute Compartment Syndrome
Full size table

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schloss, M., Weir, T.B., Jauregui, J.J. et al. Increased morphine requirements are predictive of acute compartment syndrome in adults with tibia fractures. International Orthopaedics (SICOT) 44, 743–752 (2020). https://doi.org/10.1007/s00264-019-04455-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-019-04455-2

Keywords

Search

Navigation