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BROOKLYN, NEW YORK;
TEMPLEMAN, DAVID, M.D., MINNEAPOLIS,
MINNESOTA
An Instructional Course Lecture, The American
Academy of Orthopaedic Surgeons
J Bone Joint Surg [Am] 1996; 78-A; 1438-44
Compartment syndrome is a well recognized
complication of a fracture of the tibial shaft(3,4,6,15,31).
Despite attempts to document the pathophysiology of
compartment syndrome, the clinical recognition of
this disorder is frequently difficult. If left untreated,
compartment syndrome not only results in the loss of
nerve and muscle function but also may lead to
infection, myoglobinuria and renal failure, and even
amputation.
A closed tibial fracture is one of the conditions
most frequently associated with the development of
compartment syndrome. Compartment syndrome
occurs after both closed and open tibial fractures; the
prevalence has ranged from five (1 per cent) of 411
fractures to eighteen (9 per cent) of 198 fractures(3).
The range probably reflects the varying percentage of
high-velocity injuries seen at different medical
centers(31).
The Clinical Problem
Despite an increased sensitivity of clinicians to the
diagnosis of compartment syndrome, few criteria are
available to serve as guidelines for making the
diagnosis. The subjective criteria include pain,
sensory changes, motor function, and turgor, but the
sole objective criterion is the measurement of
intracompartmental pressures. However, even the
definition of abnormal tissue pressure is difficult, as
anatomical compartments are not homogeneous and
an equilibrium of pressure cannot be expected(18).
Heckman et al.(8) measured intracompartmental
pressures at multiple sites in patients who had a tibial
fracture. They documented localized areas of
increased tissue pressure within single compartments.
These differences were significant (p < 0.0005) at
distances of as little as five centimeters from the site
of the fracture. In twenty-four of the twenty-five
patients, the highest pressures were found in the
anterior and posterior compartments. Those authors
recommended the measurement of pressure at
multiple sites, especially at the level of the fracture,
and the careful assessment of all compartments(8).
For the clinician, the fundamental problem is the
inability to identify the pressure at which nerve and
muscle become ischemic. There is no reliable
objective method to determine when a fasciotomy is
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longus muscles.
Great variation has also been found in the course of
the cutaneous branches of the superficial peroneal
nerve. Blair and Botte(2) recently reported that the
most common pattern was a single nerve that exited
the crural fascia at an average of twelve centimeters
proximal to the ankle joint and then divided into its
terminal branches approximately four centimeters
proximal to the ankle joint. In the other patterns, the
medial and intermediate dorsal cutaneous nerves
arose independently from the superficial peroneal
nerve and pierced the fascia separately; the
intermediate dorsal cutaneous nerve penetrated the
fascia at a more distal point in the leg than did the
medial dorsal cutaneous nerve (usually within about
six centimeters proximal to the ankle joint). The
intermediate dorsal cutaneous nerve may be located
anterior or posterior to the lateral malleolus and may
remain in close proximity to it.
The locations of the muscular branches of the
peroneal nerve also have been more clearly
delineated recently(26,27). In addition to its recurrent,
deep, and superficial branches, the common peroneal
nerve was found to give off several muscular
branches near the fibular neck. Most of these
branches supplied the peroneus longus and extensor
digitorum muscles. This leash of nerve fibers was
located in the anterior compartment, two to five
centimeters distal to the head of the fibula.
An important implication of these recent
anatomical studies relates to the technique used for
the release of the anterior and lateral compartments.
This can be done either by division of the deep fascia
of one compartment and then division of the
intermuscular septum for the release of the other
compartment (Fig. 1-A) or by the individual release
of each compartment through its outer fascia
(Fig. 1-B). Because of the variable location of the
superficial peroneal nerve within and crossing the
anterior compartment, the second technique is safer.
However, it must be remembered that the nerve may
lie immediately beneath the fascia and therefore may
be vulnerable to injury when this method is used.
The terminal cutaneous branches of the superficial
peroneal nerve are at risk at the distal end of the
fasciotomy after they pierce the crural fascia, most
commonly at the junction of the middle and distal
thirds of the leg, approximately twelve centimeters
proximal to the ankle. The intermediate dorsal
cutaneous nerve is at particular risk if it crosses the
fibula or lies too close to it. Likewise, care must be
taken in the proximal region of the leg to avoid
damage to the branches of the common peroneal
nerve.
Outcome of Compartment Syndrome
When the diagnosis of a compartment syndrome is
made early and a fasciotomy is performed promptly,
most patients have few sequelae. Rorabeck and
Macnab(24) documented that patients who had a
release within six hours of the diagnosis had a full
recovery, whereas those who had a release after six
hours (mean time to operation, eighteen hours) had
sequelae. In a study of the malpractice costs
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Overview
A compartment syndrome of the leg may be a
devastating complication of a tibial fracture.
Meticulous and repeated examinations of the patient
who has such a fracture are needed to ensure that the
diagnosis is not missed. In patients who are
conscious, sensory changes usually occur before
motor changes. Pain on passive stretching of the
muscles in a given compartment may be the earliest
clinical indicator(24). In patients who are obtunded or
anesthetized, objective criteria must be used to make
the diagnosis. Intracompartmental pressure is the sole
objective measurement and constitutes an indirect
measurement of muscle and nerve ischemia. We
believe that the most reliable measurement is the
difference between the diastolic blood pressure and
the intracompartmental pressure (differential
pressure, or P), and we consider a differential
pressure of less than thirty millimeters of mercury
(4.00 kilopascals) to be indicative of compartment
syndrome. Patients who are managed with tibial
nailing are at particular risk, especially if reamers and
prolonged traction are used(22,29). In these situations,
monitoring of the pressure in the anterior
compartment is a judicious step. If the nail is inserted
without the use of continuous traction or reaming,
incidental but short-lived increases in pressure will
occur, but continuous monitoring is not needed(30).
Once a compartment syndrome has been diagnosed,
emergent fasciotomy is needed to avoid permanent
neurological sequelae(24). Many techniques are
available, but regardless of the method chosen, all
four compartments must be released throughout their
entire extent. A delay of more than six hours in the
diagnosis or the fasciotomy usually leads to
permanent weakness. The surgeon must have a high
index of suspicion for compartment syndrome for all
patients who have a tibial fracture.
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