The Journal of TRAUMA威 Injury, Infection, and Critical Care

Long-term Physical Outcome of Patients Who Suffered Crush

Syndrome after the 1995 Hanshin-Awaji Earthquake:
Prognostic Indicators in Retrospect
Tetsuya Matsuoka, MD, Toshiharu Yoshioka, MD, Hiroshi Tanaka, MD, Norihisa Ninomiya, MD,
Jun Oda, MD, Hisashi Sugimoto, MD, and Junichiro Yokota, MD

Background: The 372 cases of crush
syndrome that followed the 1995 Hanshin-
Awaji earthquake have provided a unique
opportunity to investigate the long-term
physical outcomes and to establish indica-
tions for specific treatments in such pa-
tients. The objectives of this study were to
identify independent predictors of physi-
cal outcome in patients suffering from
crush syndrome and to clarify the influ-
ence of fasciotomy on outcomes.
Methods: Sensory and motor func-
tions were examined 2 years after the
earthquake in 42 patients with a total of
58 compressed lower extremities. The in-
fluences of time to rescue, fasciotomy, and
radical debridement on lower leg muscle
strength were evaluated by stepwise re-
gression analysis. Correlation between the
time to fasciotomy and lower leg muscle
strength was also analyzed.
Results: Severe disabilities related to
the lower leg compartment were present
in 47% (8/17) of patients who underwent
fasciotomy and in 16% (4/25) of patients
who did not. The anterior compartment
was damaged more severely than the pos-
terior compartment. Severe sensory and
motor disturbances occurred at a higher
rate in relation to anterior and posterior
compartments that were treated by fas-
ciotomy than in relation to those that were
not. Stepwise regression analysis showed
fasciotomy/debridement score to be an in-
dependent predictor of long-term lower
leg muscle strength (R ⴝ 0.67, p < 0.0001)
and showed time to rescue to be an inde-
pendent predictor when debrided com-
partments were not included in the anal-
ysis (R ⴝ 0.36, p ⴝ 0.009). In all debrided
anterior compartments, muscle contractil-
ity was completely abolished. There was a
significant negative correlation between
time to fasciotomy and lower leg muscle
strength.
Conclusion: Secondary compart-
ment syndrome affects physical outcome
in crush syndrome patients. We obtained
no evidence that fasciotomy improves out-
come. Delayed rescue, delayed fasciotomy,
and radical debridement may worsen the
physical prognosis. Indications for fas-
ciotomy in crush syndrome during the
acute phase need further deliberation.
Key Words: Crush syndrome, Com-
partment syndrome, Fasciotomy, Radical
debridement, Physical prognosis.
J Trauma. 2002;52:33–39.

A
t 5:46 AM on January 17, 1995, a catastrophic earth-
quake that registered 7.2 on the Richter scale hit the
southern part of Hyogo Prefecture (Hanshin area and
Awaji Island), including the city of Kobe. This Hanshin-
Awaji earthquake resulted in approximately 5,500 deaths and
41,000 casualties. After the earthquake, our hospital staff
conducted an early fact-finding survey regarding emergency
medical care. The survey involved visits to 95 hospitals
within and surrounding the damaged area and reviews of the
medical records of patients admitted after the earthquake.1,2
In the original survey, we identified 372 patients with crush
Submitted for publication November 19, 2000.
Accepted for publication September 2, 2001.
Copyright © 2002 by Lippincott Williams & Wilkins, Inc.
From Senshu Critical Care Medical Center (T.M., J.Y.), Department of
Emergency Medicine, Osaka Prefectural Hospital (T.Y.), and Department of
Traumatology and Emergency Medicine, Osaka University Hospital (H.T.,
N.N., J.O., H.S.), Osaka, Japan.
Supported by a grant from the Japanese Ministry of Health and Welfare.
Poster presentation at the 60th Annual Meeting of the American Associ-
ation for the Surgery of Trauma, October 11–15, 2000, San Antonio, Texas.
Address for reprints: Tetsuya Matsuoka, MD, Senshu Critical Care
Medical Center, 2-24 Rinku Orai-kita, Izumisano, Osaka 598-0048, Japan;
email: matsuoka@sccmc.izumisano.osaka.jp.
syndrome and clarified the clinical features, particularly in
relation to syndrome severity.3
Crush syndrome was first identified by Bywaters and
Beall4 as hemodynamic and metabolic disturbances and acute
renal failure following muscle injury due to prolonged com-
pression of a limb. There are few reports regarding the phys-
ical prognosis and treatment of crush injury to the local
extremities.5,6 Although fasciotomy is performed in muscle
compartments with extremely high intracompartmental pres-
sure to decrease the pressure and protect the muscles and
peripheral nerves from irreversible ischemic damage, the
efficacy of fasciotomy in relation to long-term outcome in
crush syndrome patients remains controversial.
Two years after the earthquake, we performed a follow-up
study of 42 crush syndrome patients to investigate sensory and
motor functions of the affected lower extremities. The objectives
of this study were to identify prognostic indicators of long-term
physical outcome in crush syndrome patients and to clarify how
fasciotomy influences outcome in such patients.
PATIENTS AND METHODS
Patients
In the original fact-finding survey, we identified 372
patients that suffered crush syndrome as a result of the earth-

Volume 52 • Number 1 33
 The Journal of TRAUMA威 Injury, Infection, and Critical Care
quake. Crush syndrome was diagnosed in patients who were
trapped under collapsed buildings by the following criteria:
(1) compression of limb muscles; (2) swelling and neurologic
disturbance of the affected area; and (3) presence of an
abnormal urine finding, such as anuria, myoglobinuria, or
hematuria.
For patients who had sustained crush injury in a lower
extremity and had showed a peak serum concentration of over
10,000 U/L creatinine kinase (peak CK), we requested a
medical examination either in the Department of Traumatol-
ogy, Osaka University Hospital or at a neighboring hospital.
Patients who had undergone fasciotomy in a lower extremity
were encouraged to participate in the study even if peak CK
had not been determined. Forty-two patients with 58 crushed
lower extremities consented to participate and visited our
hospital (34 patients) or other hospitals (8 patients) for clin-
ical examination of sensory and motor functions between
January and March of 1997.
Outcome Measures
The strength of each of nine lower extremity muscle
groups was graded from 0 to 5 according to the Medical
Research Council (MRC) grading system, and residual weak-
ness was classified as severe (MRC grades 0 and 1), moderate
(MRC grades 2 and 3), or mild/none (MRC grades 4 and 5).
Muscle strength was evaluated separately in the anterior and
posterior (superficial and deep posterior) lower leg compart-
ments. The total MRC score for the anterior tibial muscle and
toe extensor was used for the anterior compartment, and that
of the gastrocnemial muscle and toe flexor was used for the
posterior compartment. The total score of these four muscles
was calculated to evaluate motor function of the lower legs.
Light touch and pinprick sensations were examined in
five peripheral nerve regions of the foot: dorsal surface for
the superficial peroneal nerve, web space between the hallux
and second toe for the deep peroneal nerve, lateral side of the
ankle and foot for the sural nerve, plantar surface for the tibial
nerve, and medial side of the ankle and foot for the saphenous
nerve. The results were graded from 0 to 2 (0, anesthesia; 1,
hypo- or hyperesthesia; 2, normal). The total scores of touch
and pain were used to grade the residual sensory disturbance
in each peripheral nerve region as follows: severe/anesthesia
(0 and 1), hypo- or hyperesthesia (2 and 3), or normal (4).
We also measured range of motion (ROM) in the hip,
knee, ankle, and toe joints, and a loss of active and passive
ROM was considered articular contracture. Severe physical
disability was defined as either severe weakness of at least
one muscle group, severe/anesthetic sensory disturbance of at
least one peripheral nerve region, or articular contracture.
Other Data Obtained from the Medical Records
We obtained the following patient information from their
medical records: sex, age, anatomic injury site, time from the
injury to rescue (time to rescue), time from the injury to
hospital admission for definitive therapy (time to admission),
34
peak CK, the occurrence of acute renal failure defined as a
serum concentration of creatinine ⬎ 2.5 mg/dL or anuria,
need for hemodialysis, the site of fasciotomy, time from
the injury to fasciotomy, and the performance of radical
muscle debridement following fasciotomy. Fasciotomy and
radical debridement were also scored: 0, no fasciotomy; 1, fas-
ciotomy of an anterior or posterior compartment; 2, fasciotomy
with radical debridement.
Statistical Analysis
Numerical data are presented as mean ⫾ SD values.
Measures were compared statistically by unpaired t test and
␹2 test between patients who underwent fasciotomy and those
who did not. Correlations between total lower leg muscle
strength and sex, age, time to rescue, and fasciotomy/debride-
ment score were examined by stepwise regression. The same
correlations were examined for muscle strength in the ante-
rior or posterior compartment. In 21 fasciotomized lower
legs, correlation between time from rescue to the perfor-
mance of fasciotomy and the total lower leg muscle strength
score was analyzed by simple regression. Statistical signifi-
cance was assumed at p ⬍ 0.05.
RESULTS
Characteristics of the 42 patients included in this fol-
low-up study are shown in Table 1. Fifty-eight lower extrem-
ities were crushed, and 22 extremities in 17 patients were
fasciotomized. Fasciotomy and nonfasciotomy patients were
similar in age, sex distribution, occurrence rate of acute renal
failure, and percentage of patients requiring hemodialysis.
Patients had been trapped under collapsed houses for 7.0 ⫾
3.3 hours (range, 3 to 20 hours). A significant difference in
the time to rescue was found between the fasciotomy and
nonfasciotomy patients (p ⫽ 0.02). The average time from
insult to hospital admission for definitive therapy was 19 ⫾
18 hours (range, 6 to 72 hours), and there was no significant
difference between the two groups (p ⫽ 0.17). Peak CK
ranged from 10,000 to 241,000 U/L, and no significant dif-
ference existed between the fasciotomy and nonfasciotomy
patients (p ⫽ 0.16). Fasciotomy was performed in 7 thighs,
16 anterolateral lower leg sites, and 17 posteromedial lower
leg sites in 22 extremities. The time from insult to fasciotomy
was 52.8 ⫾ 57.8 hours (12 to 240 hours), and fasciotomies in
five patients were performed more than 72 hours after injury.
Six legs of five patients required radical debridement after
fasciotomy. Infection occurred at the fasciotomy site in three
legs of two patients.
Residual motor and sensory disturbances in the 58
crushed legs are shown in Tables 2 and 3. Severe residual
thigh muscle weakness was not found, whereas severe lower
leg disability was observed in several patients. In the anterior
lower leg compartments, 9 anterior tibial muscles, 12 toe
extensors, and 8 deep peroneal nerves showed severe muscle
weakness or sensory disturbance, whereas in the superficial
and deep posterior compartment, 1 gastrocnemial muscle, 2
January 2002
 Physical Prognosis of Crush Syndrome

Table 1 Characteristics of Patients Included in the Follow-Up Study

Fasciotomy Nonfasciotomy Total

No. of patients 17 25 42
No. of legs 22 36 58
Male/female ratio 6/11 12/13 18/24
Age (yr) 49 ⫾ 16 47 ⫾ 19 48 ⫾ 18
Time to rescue (hr) 8.3 ⫾ 4.5† 6.2 ⫾ 2.0 7.0 ⫾ 3.3
Time to admission* (hr) 24 ⫾ 20 16 ⫾ 17 19 ⫾ 18
Peak CK (U/L) 101,000 ⫾ 72,000*** 71,000 ⫾ 55,000 82,000 ⫾ 63,000
Number of patients with ARF** 13 21 34
Number of patients with HD 13 13 26
Site of fasciotomy
Thigh 7****
Lower leg 21
Anterolateral site 16
Posteromedial site 17
Time from injury to fasciotomy [range] (hr) 52.3 ⫾ 58.0 [12–240]*****
ARF, acute renal failure; HD, hemodialysis.
* Time to admission; time from the injury to hospital admission for definitive therapy.
** ARF was defined as serum concentration of creatinine ⬎ 2.5 mg/dL or anuria.
*** For three fasciotomy patients, peak CK data were missing.
**** Six legs also had lower leg fasciotomies.
***** In five patients, fasciotomies were performed more than 72 hours after injury.
†
p ⬍ 0.05 vs. nonfasciotomy patients.

toe flexors, 1 tibial nerve, and 1 sural nerve showed severe (p ⫽ 0.004) muscles, the superficial (p ⫽ 0.003) and deep (p
muscle weakness or sensory disturbance. Significant differ- ⫽ 0.03) peroneal nerves, and the tibial nerve (p ⫽ 0.01).
ences were observed between fasciotomy and nonfasciotomy The patients with severe disability (eight fasciotomy and
patients in the severity of residual disturbance in the anterior four nonfasciotomy patients) are summarized in Table 4.
tibial (p ⫽ 0.0009), toe extensor (p ⬍ 0.0001) and toe flexor Three of these patients underwent fasciotomy more than 72
hours after injury. Radical debridement was required in six
lower legs of five patients due to massive muscle necrosis or
Table 2 Residual Muscle Weakness in Each Muscle
infection. Contraction was found in six ankle and six toe
Group
joints of five fasciotomy patients and four ankle and three toe
Severity of Muscle Weakness
Muscle Group Fasciotomy joints of four nonfasciotomy patients. These joint contrac-
Severe Moderate Mild/None tures were associated with severe muscle weakness. Four
Iliopsoas* (⫹) — — — nonfasciotomy patients showed severe changes in the anterior
(–) 0 7 51 compartment, including anterior tibial muscle and toe exten-
Abd. coxa* (⫹) — — —
sor weakness and sensory disturbance of the deep peroneal
(–) 0 8 50
Add. coxa (⫹) 0 2 4 nerve region. All four patients who did not undergo fas-
(–) 0 8 44 ciotomy but showed severe muscle weakness also presented
Quadriceps (⫹) 0 1 6 severe sensory disturbance, whereas only three of eight pa-
(–) 0 3 48 tients who underwent fasciotomy and showed severe muscle
Hamstring* (⫹) — — —
(–) 0 6 52 weakness presented severe sensory disturbance (p ⫽ 0.04).
Tibialis anterior# (⫹) 7** 3 6 None of these 12 patients had an advancing Tinel sign over a
(–) 2 8 32 peripheral nerve. All patients are able to walk, although one
Ext. toe# (⫹) 9** 4 3 fasciotomy patient needs an ankle-foot orthosis and one non-
(–) 3 5 34
Flex. toe# (⫹) 1*** 8 8
fasciotomy patient needs a cane. Reconstructive procedures
(–) 1 4 36 were done in only 4 of 42 patients. Two nonfasciotomy
Gastrocnemius (⫹) 1*** 3 13 patients (patients 11 and 12) had left Achilles tendon length-
(–) 0 3 38 ening over 1 year after injury. One fasciotomy patient (patient
Abd., abductor; Add., adductor; Ext., extensor; Flex., flexor. 4) had left Achilles tendon lengthening over 1 year after
* Fasciotomy not performed in this muscle group. injury, and another fasciotomy patient (patient 5) had tendol-
** Including six legs that were radically debrided.
*** Radically debrided.
ysis for both toe extensors and the left anterior tibial tendon
#
Significant difference between fasciotomy and nonfasciotomy as well as arthrolysis for the right ankle joint within 1 year
patients. after injury.

Volume 52 • Number 1 35
 The Journal of TRAUMA威 Injury, Infection, and Critical Care

ysis of the posterior compartment, the only significant inde-

Table 3 Sensory Disturbance in the Region of Each
pendent variable was time to rescue (R ⫽ 0.50, p ⫽ 0.0002),
Peripheral Nerve
but when debrided fasciotomy was included, the only signif-
Severity of Disturbance icant independent predictor was fasciotomy/debridement
Region Fasciotomy Severe/ Hypo-/
Normal score (R ⫽ 0.46, p ⫽ 0.0003) (Fig. 2). For the anterior
Anesthesia Hyperesthesis
compartment, the fasciotomy/debridement score proved to be
Superficial peroneal# (⫹) 2 13 1 an independent predictor, when debrided fasciotomy was
(–) 0 23 19
included (R ⫽ 0.72, p ⬍ 0.0001) and excluded (R ⫽ 0.36, p
Deep peroneal# (⫹) 4 11 1
(–) 4 21 17 ⫽ 0.009) (Fig. 3). All six anterior compartments in which
Tibial# (⫹) 1 12 4 radical debridement was done had muscle strength scores of
(–) 0 15 26 0, whereas the posterior compartments in which debridement
Sural (⫹) 1 10 6 was done had muscle strength scores of over 4, excluding the
(–) 0 15 26
one case in which fasciotomy and radical debridement were
Saphenous* (⫹) — — —
(–) 1 33 24 performed 10 days after the earthquake. In the fasciotomy
patients, significant correlation was shown between the time
* Not belonging to any muscle compartments.
#
Significant differences between fasciotomized and nonfas-
from rescue to the performance of fasciotomy and the total
ciotomized compartments, including each peripheral nerve. lower leg muscle strength score (R ⫽ 0.49, p ⫽ 0.03) (Fig. 4).

The total lower leg muscle strength scores were signifi-

cantly correlated with the fasciotomy/debridement scores (R
⫽ 0.67, p ⬍ 0.0001). All legs treated by both fasciotomy and
radical muscle debridement had lower leg muscle strength
scores of less than 10 (Fig. 1). In stepwise regression analysis
that excluded debrided muscles, fasciotomy scores did not
prove to be independent predictors of outcome, but time to
rescue did prove to be an independent predictor (R ⫽ 0.36, p
⫽ 0.009). When debrided fasciotomy was excluded in anal-
DISCUSSION
In our early fact-finding survey, we clarified the clinical
features and severity of crush syndrome in the early phase
after the earthquake,3 but the long-term physical outcome of
crush syndrome could not be determined. A few reports refer
to this matter,5,6 but the sample populations are small and the
reports fail to clarify the physical prognoses. Thus, we per-
formed the current follow-up study of patients with crush

Table 4 Summary of Patients with Severe Disability

Peak CK Time to Time to Sensory Motor
Patient Age (yr) Sex Debridement Contracture
(U/L) Rescue (hr) Fasciotomy (hr) Disturbance Disturbance

Fasciotomy performed
1 50 M 171,000 5 240 (⫹) 5 regions of rt rt TA, rt GC rt ankle
foot rt Ext/Flex toe rt toe
2 26 F 87,900 4 12 (⫹) rt TA
rt Ext toe
3* 57 F 77,700 8 32 (⫹)* lt s/d peroneal bil TA bil ankle
rt d peroneal bil Ext toe bil toe
4 45 M 62,200 5 24 (–) lt Ext toe lt ankle
lt toe
5 47 M 48,600 20 32 (⫹) rt TA
rt Ext toe
6 42 F 35,700 6 120 (⫹) rt TA rt ankle
rt Ext toe rt toe
7 43 F — 9 72 (–) lt Ext toe
8 62 F — 10 20 ? lt d peroneal lt TA lt ankle
lt Ext toe
Fasciotomy not performed
9 53 F 135,500 6 — — lt d peroneal lt TA lt ankle
lt Ext toe
10 25 M 98,600 9 — — lt d peroneal rt Ext toe lt ankle
rt toe
11 18 F 77,300 10 — — lt d peroneal lt Ext/Flex toe lt ankle
lt toe
12 22 M 36,700 10 — — lt d peroneal lt TA lt ankle
lt Ext toe lt toe
rt/lt, right/left; bil, bilateral; d/s, deep/superficial; TA, anterior tibial muscle; GC, gastrocnemius muscle; Ext/Flex, extensor/flexor.
* Bilateral fasciotomy and radical debridement.

36 January 2002

Fig. 1. Correlation between time to rescue and total lower leg
muscle strength score. Nonfasciotomized lower leg (filled circles),
fasciotomized lower leg (open squares), and lower leg radically
debrided after fasciotomy (filled squares). According to stepwise
regression analysis, fasciotomy/debridement score was the only in-
dependent predictor of total lower leg muscle strength (R ⫽ 0.67, p
⬍ 0.0001), whereas time to rescue was the only predictor when
debrided lower legs were excluded (R ⫽ 0.36, p ⫽ 0.009).
syndrome to clarify determinants of physical prognosis as
well as the influence of fasciotomy on long-term outcome.
We reported from the previous study that peak CK val-
ues reflected the amount of damaged muscle as well as the
severity of crush syndrome in the early phase;3 however, no
significant correlations between peak CK values and long-
term physical outcomes were observed in the present study
(data not shown). Severe residual disabilities were thought to
result from direct injury to the muscles and peripheral nerves,
ischemia/reperfusion injury in the muscles and peripheral
nerves, and compartment syndrome due to primary compres-
sion and secondary muscle swelling. All of the muscle groups
showing severe residual damage were of the lower leg with
firmer compartments than the thigh (Table 2). No patient
manifested the advancing Tinel sign over a peripheral nerve,
which results from direct injury to the nerve. Our findings
indicate strongly that lower leg compartment syndrome con-
tributes to the long-term physical disability of crush syn-
drome patients. Furthermore, of the lower leg compartments,
the anterior compartment was more susceptible to damage
than the posterior compartment.
The time to rescue, the time to performance of fas-
ciotomy, and the need for radical debridement were initially
thought to be prognostic indicators of physical outcome.
According to stepwise regression analysis, only fasciotomy/
debridement score was shown to be an independent determi-
nant of muscle strength. When debrided muscles were ex-
cluded from analysis, only time to rescue was shown to be an
independent predictor of total lower leg muscle strength and
posterior compartment muscle strength. Radical debridement
with fasciotomy was linked most strongly to motor disability,
and contraction of debrided muscles failed to be observed,
especially in the anterior compartment. Fasciotomy failed to
contribute to the improvement of physical function, and the
Volume 52 • Number 1
Physical Prognosis of Crush Syndrome
Fig. 2. Correlation between time to rescue and muscle strength of
the posterior compartment. Nonfasciotomized posterior compart-
ment (filled circles), fasciotomized posterior compartment (open
squares), and posterior compartment radically debrided after fas-
ciotomy (filled squares). According to stepwise regression analysis,
fasciotomy/debridement score was the only independent predictor of
muscle strength of the posterior compartment (R ⫽ 0.46, p ⫽
0.0003), whereas time to rescue was the only predictor when de-
brided posterior compartments were excluded (R ⫽ 0.50, p ⫽
0.0002).
functional outcome of debrided muscle in the anterior com-
partment was poor. Our findings are similar to those of
several other authors5,7,8 who concluded fasciotomy to be
contraindicated for crush syndrome. The rationale is that if a
muscle is already necrotized, fasciotomy cannot reverse the
status of the muscle. In fact, it exposes the necrotic muscle to
possible infection, and debridement of a necrotic muscle
following fasciotomy can induce massive bleeding. Severe
infection or profound diffuse hemorrhage in cases of crush
Fig. 3. Correlation between time to rescue and muscle strength of
the anterior compartment. Nonfasciotomized anterior compartment
(filled circles), fasciotomized anterior compartment (open squares),
and anterior compartment radically debrided after fasciotomy
(filled squares). According to stepwise regression analysis, fas-
ciotomy/debridement score was the only independent predictor of
muscle strength of the anterior compartment both including (R ⫽
0.72, p ⬍ 0.0001) and excluding (R ⫽ 0.36, p ⫽ 0.009) debrided
anterior compartments.
37
 The Journal of TRAUMA威 Injury, Infection, and Critical Care
Fig. 4. Analysis of fasciotomized lower legs for correlation between
time from rescue to fasciotomy and the total lower leg muscle
strength score. There was a significant correlation between time
from rescue to fasciotomy and the total lower leg muscle strength
score (R ⫽ 0.49, p ⫽ 0.03).
syndrome might require amputation as a life-saving proce-
dure. In our previous study of 372 patients with crush syn-
drome, 49 patients underwent fasciotomy and 12 experienced
surgical site infection. Two patients died due to sepsis from
surgical site infection, and three patients had to undergo
amputation for the control of infection. We conclude that
infection at the fasciotomy site is a serious risk.
For compartment syndrome secondary to injury of ex-
tremity, fasciotomy is recognized as an essential treatment
that releases intracompartmental pressure and prevents irre-
versible ischemic damage of the muscle and peripheral nerve.
Sheridan and Matsen9 reported, however, that even in com-
partment syndrome, among extremities in which fasciotomy
was performed more than 12 hours after the appearance of
motor weakness, pain on passive muscle stretch, or hypes-
thesia, normal function was restored in only 8%, and late
fasciotomy increased the potential for complications such as
infection. Furthermore, restoration of the circulation by fas-
ciotomy must be done on a prophylactic basis before perma-
nent changes occur; meta-analysis has shown fasciotomy in
patients with paralysis to be unsatisfactory in over 80% of
cases.10,11 In models of total ischemia, muscles and periph-
eral nerves can survive for as long as 4 hours without irre-
versible damage, and total ischemia for more than 8 hours
produces irreversible changes.11 In postural crush syndrome,
intramuscular pressure in the volar forearms and anterior
tibial compartments that are directly compressed is suffi-
ciently high to cause muscle ischemia.12 In crush syndrome,
muscles and peripheral nerves in the trapped extremities may
already be affected by ischemia due to the increase in intra-
compartmental pressure. Recovery from complete ischemia
for more than 8 hours is not possible because muscle and
peripheral nerve deterioration is irreversible. Even if isch-
emia is only partial during the time of entrapment, the lower
leg compartment showing neurologic deficit and high intra-
compartmental pressure over 40 mm Hg or 20 mm Hg below
diastolic blood pressure13 must be fasciotomized within 12
38
hours. Mubarak and Owen6 reported two patients with pos-
tural crush syndrome who underwent immediate fasciotomy
and had a good physical outcome. In a group of crush injury
patients reported by Reis and Michaelson,5 fasciotomy was
performed more than 24 hours after injury, and later analysis
showed such fasciotomy to be contraindicated.
In the present follow-up study, we found no evidence
that fasciotomy improved outcomes in terms of physical
ability, although sensory disturbance in patients with severe
muscle weakness might have been reduced by fasciotomy
(Table 4). This study, however, was conducted retrospec-
tively, and it is possible that the initial severity of symptoms
between patients undergoing and not undergoing fasciotomy
were unequal. Unfortunately, records of intracompartmental
pressure were found for only a few patients, and the physical
symptoms of patients were unknown. Indications for fas-
ciotomy were determined by the doctors who first examined
the patients. Patients who underwent fasciotomy were more
severely injured than those who did not. In fact, the time to
rescue was significantly longer in the fasciotomy patients
than in the nonfasciotomy patients. Of 21 fasciotomized
lower legs, only seven extremities of five patients were fas-
ciotomized within 24 hours after insult, and the delay in
fasciotomy may have caused the worsening of physical out-
come, as shown in Figure 4. Furthermore, at least three of six
extremities (in patients 2 and 3, Table 4) treated with radical
debridement showed over 80 mm Hg of intracompartmental
pressure and required fasciotomy to preserve the lower
extremities.
Among the nonfasciotomy patients, four suffered severe
disability. All four manifested severe disability of the lower
leg anterior compartment and joint contractures of the ankle
and/or toe. One patient manifested severe disability of the
deep posterior compartment. These patients were rescued
within 10 hours after the earthquake, and fasciotomy might
have improved the physical outcome in these patients.
Mubarak and Owen and others6,12,14 reported that despite
high compression pressure, the area of muscle necrosis is
sharply localized and that reperfusion arising from decom-
pression with extrication causes edema and a rise in intra-
compartmental pressure, which exacerbates the myonecrosis
and neural injury. They suggested that immediate fasciotomy
and excision of the necrotic area is required for survival of the
remaining viable muscle without scar adherence and for de-
creasing the systemic effects of myonecrosis. However, Reis
and Michaelson5,7 note that fasciotomy after the muscle cells
and peripheral nerves in the compartment are necrotized
completely fails to improve the physical outcome and may
expose dead tissue to the potential for infection. Residual
viable muscle and nerve seem to be important for effective
fasciotomy. However, the means by which the remaining
viable muscle and nerve can be detected before fasciotomy
requires further investigation.
January 2002

CONCLUSION
In individuals suffering crush syndrome in the 1995
Hanshin-Awaji earthquake, physical prognosis was linked
particularly to lower leg compartment syndrome. Although
there were four nonfasciotomy patients in whom fasciotomy
might have been indicated, evidence that fasciotomy im-
proved physical outcome is lacking, and patients who under-
went radical debridement after fasciotomy manifested the
most severe loss of muscle strength. Delayed fasciotomy may
negatively influence the physical outcome, and indications
for fasciotomy in the acute phase of crush syndrome should
be carefully considered.
ACKNOWLEDGMENT
The authors thank the entire staff of the Department of Traumatology
and Emergency Medicine, Osaka University Hospital, Osaka, Japan, for their
assistance with the original survey.
REFERENCES
1. Tanaka H, Iwai A, Oda J, et al. Overview of evacuation and
transport of patients following the 1995 Hanshin-Awaji earthquake.
J Emerg Med. 1998;16:439 – 444.
2. Tanaka H, Oda J, Iwai A, et al. Morbidity and mortality of
hospitalized patients after the 1995 Hanshin-Awaji earthquake. Am J
Emerg Med. 1999;17:186 –191.
3. Oda J, Tanaka H, Yoshioka T, et al. Analysis of 372 patients with
crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma.
1997;42:470 – 475.
Volume 52 • Number 1
Physical Prognosis of Crush Syndrome
4. Bywaters EGL, Beall D. Crush injuries with impairment of renal
function. BMJ. 1941;1:427– 432.
5. Reis ND, Michaelson M. Crush injury to the lower limbs.
Treatment of the local injury. J Bone Joint Surg Am. 1986;68:414 –
418.
6. Mubarak S, Owen CA. Compartmental syndrome and its relation to
the crush syndrome: A spectrum of disease—a review of 11 cases of
prolonged limb compression. Clin Orthop. 1975;113:81– 89.
7. Michaelson M. Crush injury and crush syndrome. World J Surg.
1992;16:899 –903.
8. Better OS, Stein JH. Early management of shock and prophylaxis of
acute renal failure in traumatic rhabdomyolysis. N Engl J Med.
1990;322:825– 829.
9. Sheridan GW, Matsen FA III. Fasciotomy in the treatment of the
acute compartment syndrome. J Bone Joint Surg Am. 1976;58:112–
115.
10. Bradley EL III. The anterior tibial compartment syndrome. Surg
Gynecol Obstet. 1973;136:289 –297.
11. Whitesides TE, Heckman MM. Acute compartment syndrome:
update on diagnosis and treatment. J Am Acad Orthop Surg. 1996;
4:209 –218.
12. Owen CA, Mubarak SJ, Hargens AR, Rutherford L, Garetto LP,
Akeson WH. Intramuscular pressures with limb compression
clarification of the pathogenesis of the drug-induced muscle-
compartment syndrome. N Engl J Med. 1979;300:1169 –1172.
13. Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure
measurements as a determinant for the need of fasciotomy. Clin
Orthop. 1975;113:43–51.
14. von Schroeder HP, Botte MJ. Crush syndrome of the upper
extremity. Hand Clin. 1998;14:451– 456.
39