Impact of altered consciousness on the risk of fasciotomy for acute compartment syndrome following traumatic tibial fracture.

BACKGROUND: Acute compartment syndrome (ACS) following tibial fracture is a limb-threatening emergency that relies heavily on clinical assessment for diagnosis. In patients with altered consciousness (hereafter referred to as obtunded status), key symptoms such as pain out of proportion cannot be reliably assessed, potentially influencing surgical decision-making. Whether obtunded status independently affects fasciotomy rates remains poorly understood.

OBJECTIVE: To determine whether obtunded status is independently associated with increased likelihood of fasciotomy for suspected ACS in patients with traumatic tibial fractures.

METHODS: A retrospective cohort study was performed using the National Trauma Data Bank (NTDB) from 2016 to 2018. Patients with tibial plateau (AO/OTA 41) and tibial shaft (AO/OTA 42) fractures were included. Obtunded status was defined as sedation/intubation, severe alcohol intoxication, or Glasgow Coma Scale score < 9. The primary outcome was fasciotomy during hospitalization. Multivariable logistic regression was used to evaluate the association between obtunded status and fasciotomy while adjusting for age, sex, fracture location, fracture complexity, open fracture status, and skull fracture.

RESULTS: Among 119,393 patients with tibial fractures, 6854 (5.7%) underwent fasciotomy. On univariable analysis, obtunded patients experienced higher fasciotomy rates than non-obtunded patients (7.1% vs 5.6%, p < 0.001). After multivariable adjustment, obtunded status remained independently associated with increased odds of fasciotomy (OR 1.14, 95% CI 1.03-1.25). Other significant predictors included open fractures (OR 2.00), male sex (OR 1.72), proximal tibial fractures (OR 1.68), and increasing fracture complexity (all p < 0.001). Increasing age was associated with reduced odds of fasciotomy (p < 0.001). Skull fractures were not independently associated with fasciotomy (p = 0.16).

CONCLUSIONS: Obtunded status is independently associated with a modest but significant increase in fasciotomy rates following tibial fractures. Although fracture characteristics remain the primary determinants of surgical intervention, being obtunded appears to lower the threshold for fasciotomy when clinical assessment is unreliable. These findings highlight the diagnostic challenges of ACS in obtunded patients and support further investigation into objective monitoring strategies, including continuous intracompartmental pressure monitoring, to reduce uncertainty and optimize decision-making in high-risk populations.