Session II - Tibia
Fri., 10/8/04 Tibia, Paper #6, 10:30 am
·Compartment Syndrome in High Energy Plateau Fractures and Fracture Dislocations Treated with Temporary External Fixation
Purpose: High-energy tibial plateau fractures and fracture dislocations are commonly treated with initial external fixation until the soft tissues allow for more definitive internal fixation. External fixators maintain alignment but also pull the fracture out to length, potentially increasing the compartment pressures. The purpose of this study was to review the incidence of compartment syndrome (CS) in high-energy plateau fractures (Schatzker 6) and fracture dislocations and the timing of their occurrence in relation to placement of the external fixator.
Methods: Over a 5-year period, 67 high-energy plateau fractures and fracture dislocations were treated with initial external fixation within 48 hours of injury. There were 50 fractures (type 6) and 17 fracture dislocations. All fractures were classified prospectively in a database. Compartment syndromes were documented prospectively, and all patients were examined for signs of missed CS during office visits. The timing of the CS was noted as present at presentation, diagnosis after external fixation but during the initial operative session, late (diagnosis made postoperatively <48 hours and treated with release), or missed (findings occurring late, after permanent muscle damage).
Results: Overall, there were 18 (27%) compartment syndromes in 67 extremities:
| Injury | N | CS* | Presentation | Dx at first op session | Dx late | Missed |
| Fracture | 50 | 9 (18%) | 5 |
2 |
1 |
1 |
| Fx - Disl | 17 | 9 (53%) | 3 |
2 |
2 |
2 |
Total |
67 | 18 (27%) | 8 |
4 |
3 |
3 |
Compartment syndrome was more common after fracture dislocations than plateau fractures (P = 0.009, chi square). A diagnosis of CS was mostly made after frame placement (10), either in the operating room at the initial session (4 of 10) or within the first 48 hours after frame placement (3 of 10). There were three missed injuries, found after CS had run its course, either on the initial admission (1) or subsequent evaluation (2). All three of these patients had external fixators that included the foot in the neutral position, precluding examination of ankle motion for strength or pain on passive stretch. In contradistinction, the three patients, whose diagnosis was made within 48 hours after the first operative session, all had frames that did not include the foot.
Conclusion: The incidence of CS after placement of external fixation for high-energy plateau fractures and fracture dislocations is high, and vigilance is required to avoid missed injuries. Placement of the fixator places the compartments on stretch and may increase the risk of CS. In particular, fracture dislocations are at highest risk (53%) for CS after placement of external fixation. Finally, inclusion of the foot in the frame diminishes the ability to fully examine the extremity for CS and contributed to three missed diagnoses in this series. We recommend careful monitoring of all high-energy plateau fractures and fracture dislocations after placement of spanning external fixators. We also recommend that the foot be left out of the construct to allow for examination of active and passive ankle motion.