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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

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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 2,5 mm, light reflex +/+
E : T = 36,7
0
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 (+)






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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

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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

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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

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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 patients 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


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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

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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.

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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

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compromise the skins vascularity and viability after the procedure. Matsen et al.
(1980) used the Patman and Thompsons 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.

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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.


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