COMPARTMENT SYNDROME OF THE RIGHT LEG DUE TO

CLOSED FRACTURE OF THE RIGHT HEAD FIBULA AND

CLOSED FRACTURE OF TIBIAL PLATEAU

INTRODUCTION

Compartment syndrome is a condition whereby an increase in the pressure

within a closed osteo-fascial compartment causes a reduction in capillary perfusion to

less than that required for tissue viability, with resultant tissue ischaemia, necrosis and

late contracture if left untreated (Andrew et al. 2001, Bae et al. 2001). The condition

represents a true surgical emergency needing early diagnosis and prompt surgical

decompression to prevent permanent damage to the structures within the affected

compartment (Rorabeck 1984, Bae et al. 2001).

A case of acute compartment syndrome occurring after a tibial fracture is

presented to highlight the fact that its diagnosis is not usually straightforward. Current

views pertinent to the diagnosis and the role of intracompartmental pressure

measurement in establishing the diagnosis and dictating treatment decision (regarding

surgical timing, types of fasciotomy, fasciotomy wound closure and fracture

stabilization techniques) are discussed.

CASE SUMMARY

Name : Mr. S

Age : 48 years old

Sex : Male

Date of admittance : July 11th 2013

Reg : 61.84.64

Chief complaint : Pain at Right Leg

Suffered since 2 days before admitted to hospital due to occupational accident

1

Mechanism of trauma The patient was riding a motorcycle and then hit by a car

from behind. History of unconscious (-), nausea (-), vomit (-)

Primary Survey

A : Patent

B : RR = 20 x/min, symmetrical, spontaneous, thoraco- abdominal type.

C : BP = 120/70 mmHg, PR = 80 x/min regular, strong.

D : GCS 15 (E4M6V5), pupil isochors ø 2,5 mm, light reflex +/+

E : T = 36,70 C (axillar)

Secondary Survey

Right Knee region

I : Deformity (+), swelling (+), Hematoma (+), Wound (-)

P : Tenderness (+), Ballotement (+)

ROM : Active and passive motion of the leg cannot be evaluated due to pain

NVD : Good sensibility, dorsalis pedis artery is palpable,

Capillary refill time < 2 secs, extend big toe (+)

Right Leg Region

I : Deformity (+), swelling (+), Hematoma (+), Wound (-), Shiny skin

(+), Bulla (+) at anterior middle aspect

P : Tenderness (+), Passive strecthing pain (+)

ROM : Active and passive motion of the leg cannot be evaluated due to pain

NVD : Good sensibility, dorsalis pedis artery is palpable,

Capillary refill time < 2 secs, extend big toe (+)

2

DISCUSSION

Acute limb compartment syndrome (ALCS) was first recognized by Volkmann

in 1881 when he described the contracture that is a common late sequela of this

condition. Traumatic compartment syndrome associated with long bone fractures

accounted for 69% of the cases (Mc Queen et al. 2000) with involvement of tibial

diaphyseal fractures and fractures of the distal radius in 36% and 9.8% respectively.

The incidence of compartment syndrome after a tibial diaphyseal fracture is 2.6% (Mc

Queen et al. 1996).

Causes of ALCS are multiple, with tibial shaft fractures being the most

common orthopaedic cause for ALCS of the leg (Table 1).

Table 1 : Common causes of acute compartment syndrome

(Source : Tiwari et al. BJS. 2002; 89: 397-412)

Orthopaedic Tibial fracture

Forearm fracture

Vascular Ischaemia - reperfusion injury

Haemorrhage

Phlegmasia caerulea dolens

Iatrogenic Vascular puncture (in anticoagulated patients /

haemophiliacs)

Intravenous / intra-arterial drug injection

Soft tissue injury Prolonged limb compression

Crush injury

Burns

The four compartments of the leg are the anterior, lateral and the superficial

and deep posterior compartments. The anterior or extensor compartment of the leg is

the space between the deep fascia and the interosseous membrane, bounded medially 3

by the anterolateral surface of the tibia and laterally by the extensor surface of the

fibula and the anterior intermuscular septum. The muscles within this compartment

are the tibialis anterior, extensor hallucis longus, extensor digitorum longus and

peroneus tertius. The anterior tibial vessels and the deep peroneal nerve also run their

course within this compartment. The lateral or peroneal compartment is bounded

medially by the peroneal surface of the fibula, anteriorly by the anterior intermuscular

septum and posteriorly by the posterior intermuscular septum. The peroneus longus

and brevis muscles form the bulkiness of this compartment, along with the superficial

peroneal nerve which runs through it. The posterior or flexor compartment is

enveloped by the posterior portion of the deep fascia and is bounded anteriorly by the

posterior surfaces of the tibia and fibula and the intervening interosseous membrane.

The deep transverse fascia divides the muscles of this compartment into the

superficial and deep groups. The gastrocnemius, plantaris and soleus muscles are

within the superficial group while the deep group comprises of the popliteus, flexor

digitorum longus, flexor hallucis longus and tibialis posterior muscles. The posterior

tibial vessels and nerve passes through the deep component of this compartment.

In studies involving intra-compartmental pressure (ICP) measurements, the

anterior compartment is frequently used for monitoring and recording purposes (Mc

Queen et al. 1996, Tornetta et al. 1997, Willy et al. 1999, Mc Queen et al. 2000,

Janzing et al. 2001). It has been shown that pressure within this compartment rises

earlier than the others in cases of impending compartment syndrome, besides it being

the most common compartment affected by this condition (Mc Queen et al. 2000).

The anterior compartment is the worse-affected compartment basically due to its

singular blood supply.

Tibial fracture leads to swelling within a compartment (either as a result of

bleeding from the fracture site or from inflammation). This increases the intra-

compartmental pressure (ICP) that, after a certain level, leads to compressive closure

of the thin-walled venules and a resultant increase in hydrostatic pressure in the

capillary beds. Escape of fluid into the surrounding tissue from this effect will cause

further increase in ICP and the vicious cycle continues. Further ICP increase will later 4

cause arteriolar compression with resultant muscle and nerve ischaemia. Muscle

infarction and nerve damage will take place if decompression is not carried out

promptly (Tiwari et al. 2002).

Pain (out of proportion to the injury) and paraesthesia are the usual symptoms

in patients with suspected ALCS. The consistent signs are tense, swollen

compartments, pain on passive stretching of the involved muscles and loss of

sensation (Janzing et al. 2001). These symptoms and signs are not reliable in children,

in patients who received regional anaesthesia, in brain-injured and/or multiply-injured

patients, in patients with concomitant spinal cord injury and in unconscious patients

(Price et al. 1996, Garr et al. 1999, Bae et al. 2001, Langston et al. 2002, Tiwari et al.

2002).

This patient presented with both symptoms of severe limb pain and

paraesthesia plus a useful sign of severe tenderness on extension of the big toe (even

though this sign indicates that the anterior compartment was involved). He would

have benefited from compartmental pressure monitoring to prevent the delayed

diagnosis.

As pain-tolerance in different individuals varies, also because in some patients

the signs and symptoms are not reliable, some authors advocate intra-compartmental

pressure (ICP) monitoring using several techniques as described in literatures

(Rorabeck et al. 1984, Mc Queen et al. 1996, Garr et al. 1999, Willy et al. 1999, Bae

et al. 2001). Normal intracompartmental tissue pressure ranges between 0 and 10

mmHg. Capillary blood flow compromise may occur at pressures greater than 20

mmHg, while muscle and nerve ischaemia takes place at pressures between 30 and 40

mmHg. Irreversible damage may occur at higher pressure levels or even at a lower

level if the pressure is sustained without decompression (Andrew et al. 2001). ICP

monitoring has the benefits of detecting early compartmental pressure rise, confirms

clinical diagnosis and prompting surgeons toward timely and accurate decompression

in order to prevent the disastrous sequelae. Mc Queen et al. (1996) reviewed 25

patients with acute compartment syndromes and found out that continuous 5

compartment monitoring managed to reduce the average delay from injury time to

fasciotomy by half (32 hours to 16 hours, p < 0.05). They also found out that among

patients in the non-monitored group, 10 out of 12 developed sequelae with muscle

weakness and contractures as compared to none in the monitored group.

This patient’s fasciotomy was done 23 hours after the initial injury, which

means that if compartment syndrome had occurred from the time of injury, the

muscles in the deep compartment may have suffered ischaemia for more than 20

hours. Even though no compartmental pressures were taken before decompression, if

the worse scenario is taken into account, muscle ischaemia would have occurred from

the out start. This would have explained the weakness that this patient had in his right

foot during his follow-up.

Numerous studies have been performed to find out the correct pressure

threshold for decompression. Some suggested absolute pressure reading while others

used pressure difference relative to the blood pressure of the patients :-

Table 2 : Various studies on intracompartmental pressure monitoring in the

diagnosis of compartment syndrome and the pressure threshold used for

decompression.

Threshold used for decompression Authors

ICP > 30 mmHg

ICP > 20 mmHg

ICP > 30 mmHg + clinical diagnosis

DBP - ICP < 30 mmHg

< 20 mmHg

MAP - ICP < 30 mmHg

(MAP = DBP + 1/3 [SBP - DBP])

Blick et al. 1986

Obada et al. 1999

Rorabeck et al. 1984

Georgiadis et al. 1995

Mc Queen et al. 1996

Janzing et al. 2001

Heckman et al. 1994

Heppenstall et al. 1988

6

ICP - Intracompartmental Pressure

MAP - Mean Arterial Pressure

DBP - Diastolic Blood Pressure

SBP - Systolic Blood Pressure

Rorabeck used the absolute pressure of 30 mmHg as the cut-off point based on

observations by Rorabeck and Clarke in animals (1978) that nerve and muscle

function returned to normal provided that fasciotomy is done within 24 hours and that

the pressure does not exceed 40 mmHg at the time of fasciotomy. They further found

out that earlier fasciotomy gave better outcome compared to those where fasciotomy

was performed after 24 hours (Rorabeck et al 1984).

Janzing et al. (2001) reviewed various pressure thresholds used and concur

with some authors that it is the pressure difference and not the absolute pressure that

is important, as the former takes into account the effects of hypotension and shock on

tissue pressure in a compartment. He also noted that using the pressure difference

suggested by Heppenstall et al. (1988) – i.e. (MAP - ICP < 30 mmHg) had resulted in

a 99% specificity for detecting compartment syndromes. However the sensitivity of

this method is low, with possible missed diagnosis. Janzing et al. (2001) also

commented on the use of absolute pressure for diagnosing compartment syndromes.

This method has a high sensitivity but a low specificity, resulting in unnecessary

fasciotomies being performed to patients. This opinion is consistent with findings by

Mc Queen et al. (1996). They found out that the use of absolute pressures of 30

mmHg and 40 mmHg would have resulted in fasciotomies being done to 43% and

27%, (respectively) of patients in their series instead of 2.6% when using differential

pressure.

Despite all the opinions mentioned, the ideal pressure threshold for

decompression remains unknown (Janzing et al. 2001, Tiwari et al. 2002). It seems

more appropriate to use pressure difference instead of absolute pressure to prevent

unnecessary fasciotomies. However surgeons must bear in their minds that using this 7

method can give rise to a missed diagnosis of compartment syndrome.

Heckman et al. (1994) studied the pressure readings at various levels taken

relative to the fracture site and found out that peak pressure usually occurred at the

level of the fracture and within 5 cm from it. They found out that the pressure

readings decreased as much as 20 mmHg within 5 cm from the site where peak

pressure was recorded. They suggested that pressure readings should be performed at

the level of the fracture or within 5 cm from it in order to avoid underestimation of the

maximum compartment pressure.

The aim of fasciotomy is expedient, complete release of all tight fascial

envelopes (Matsen et al. 1980). Many authors concur in releasing all four

compartments even though only one compartment is involved (Matsen et al.1980,

Rorabeck et al. 1984, Blick et al. 1986, Mc Queen et al. 1996, Tiwari et al. 2002). In

studies by Mc Queen et al. (1996), they experienced a situation where patients, in

whom decompression of only the anterior and lateral compartments were performed,

later required a second procedure to decompress the deep posterior compartment

(number of patients not stated). Matsen et al. (1980) also had 2 patients who had to

undergo a secondary fasciotomy to release the deep posterior compartment after an

initial procedure to release only the anterior compartment.

Matsen et al. (1980) utilized the four-compartment parafibular approach in

their series with good results in all fourteen cases. A single incision is made in the

lateral part of the leg from the fibular neck to the lateral malleolus. The lateral

compartment is released first, followed by decompressing the anterior compartment

after elevating the anterior skin. Care is taken in the process not to injure the

superficial peroneal nerve, which runs its course deep to the anterior intermuscular

septum at the junction between the middle and distal third of the incision. Next the

posterior skin is retracted, exposing the fascia of the superficial posterior

compartment, which is opened. Muscles of the lateral compartment are elevated

anteriorly together with the lateral intermuscular septum and the soleus is released

from the fibular shaft, exposing the deep posterior fascial envelope, which is incised. 8

Rorabeck et al. (1984) used a double-incision fasciotomy (as described by Mubarak

and Owen in 1977) for his series. This consists of an incision made halfway between

the crest of the tibia and the fibula with the second incision made on the

posteromedial aspect of the leg approximately 2 cm from the posterior border of the

tibia. The first incision is used to decompress the anterior and lateral compartments

while the second incision decompresses the superficial and deep posterior

compartments. This method is quicker, carries less risk to the neurovascular structures

and allows adequate decompression of the posterior compartment as compared to the

single incision fibulectomy method (Tiwari et al. 2002). Blick et al. (1986) advised

against the fibulectomy method, as this particular bone has proven to be invaluable in

late osseous reconstructive procedures.

Limited skin incision in fasciotomy is undesirable by some (Blick et al. 1986,

Cohen et al. 1991, Tiwari et al 2002), as the skin itself may act as a barrier to adequate

decompression. Tiwari et al. (2002) suggested a skin incision length of 12 - 20 cm

(average 16 cm) to allow adequate compartment release. However, Cohen et al.

(1991) found out that a skin incision of 8 cm in length will reduce the mean ICP from

48 to 25 mmHg.

Skin closure after fasciotomy can be done either as a primary or delayed

primary procedure. This is decided by individual surgeons based on the mechanism of

injury, clinical presentation, presence or absence of an open fracture and the

intraoperative findings (Bae et al. 2001). Most authors prefer to go in again at 48 to 72

hours after fasciotomy for a second look at the muscles and skin closure. Method of

skin closure is decided depending on whether or not the skin edges can be

approximated to allow suturing. Georgiadis et al. (1995) suggested that in cases of

double incision fasciotomy, the medial wound should be closed first by a delayed

primary method, as this wound is more subcutaneous and closer to the fracture site.

The lateral wound should be dealt with next, closed either by suturing or by split skin

graft. The opposite was done for this patient, the possible explanation for this may be

because the medial wound is wider and more difficult to close by a delayed primary

method and over-enthusiastic undermining of skin to allow closure by suturing may 9

compromise the skin’s vascularity and viability after the procedure. Matsen et al.

(1980) used the Patman and Thompson’s progressive wound approximation technique

in cases where delayed primary suturing cannot be accomplished. This technique is

done by applying sterile paper tapes on to the wound each day, and was noted to have

reduced the wound size from 14 cm wide to a scar one-half cm wide in two of their

patients. However it was not stated whether this technique has significantly prolonged

hospital stay in these two patients.

As fracture of the tibia is one of the leading causes of compartment syndrome

of the leg, it is worthwhile to discuss regarding fracture stabilization in the setting of a

compartment syndrome following this fracture. Rorabeck (1984) and Georgiadis

(1995) both agreed that fasciotomy converts a closed fracture into an opened one, thus

destabilizing the fracture further. They suggested that this situation is an absolute

indication for operative stabilization of the fracture. Stabilization of tibial fractures

after fasciotomy helps to maintain fracture reduction, allows ready access to the soft

tissue and the wound as well as protecting it in order to facilitate healing (Matsen et

al. 1980, Rorabeck et al. 1984, Georgiadis et al. 1995). Methods of stabilization

include external fixation and internal fixation such as plating and intramedullary

nailing. Ideally any procedures performed should be aimed at minimizing trauma to

an already injured extremity. External fixation accomplishes all of the above functions

but has the setback of pin-tract infections and the need for possible further procedures.

Plating results in additional bony stripping and further soft tissue compromise.

Nailing, if requires reaming, may affect healing by damaging endosteal blood supply

which contributes significantly towards callus formation. Furthermore, reaming may

provoke further tissue damage and, along with manipulation and traction, may

increase compartment pressures (Georgiadis 1995).

In this patient, external fixation followed by conversion to locked nailing

when the risk of compartment syndrome is minimal has the benefits of allowing

proper wound management while maintaining stability at the fracture site, as well as

allowing reaming to be done without the fear of increasing the compartment

pressures. 10

Another important issue is whether nailing a closed tibial fracture can have a

positive reinforcing effect on compartment pressure rise. Tischenko et al. (1990)

found out that three of their patients developed increase in compartment pressure after

tibial intramedullary nailing with reaming. An additional two out of seven

prospectively studied patients also developed the similar problem with reamed

intramedullary nailing irrespective of duration after injury in which the procedures

were performed. However they noted that the pressure increase is more related to

prolonged, forceful traction applied during reduction and not the reaming process. Mc

Queen et al. (1996) suggested that increase in compartmental pressure is more likely

to be caused by reduction rather than reaming. This so-called ‘finger-trap

phenomenon’, in which compartment pressures rise when a tibial fracture is pulled to

length, was noted to be responsible for pressure increase in their studies. An earlier

study done in 1990 by the same author also noted that pressure increase during

reaming was only transient, and pressure fell back to its original level within seconds

of removing the reamer.

Tornetta et al. (1997) suggested the use of non-reamed, no-traction method of

nailing a tibial fracture to reduce the incidence of compartment syndrome. Nassif et

al. (2000) suggested acute nailing in order to minimize traction and prevent difficult

reduction that may cause excessive manipulation of the fracture site. They found out

that there were no statistically significant compartmental pressure differences between

reamed and non-reamed nailing that were done within three days of injury, where

reductions were performed with less manipulation and traction.

CONCLUSION

It is of utmost importance to recognize a compartment syndrome especially in

high risk and unpredictable patients. A high index of suspicion is invaluable

particularly in inconspicuous cases. Prompt decompression upon diagnosis will

prevent devastating complications and disability in these patients.

11

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