Thurs., 10/16/08 Tibia/Polytrauma, Paper #15, 4:50 pm OTA-2008
Compartment Syndrome of the Leg Associated with Fracture: An Algorithm to Avoid Releasing the Posterior Compartments
Paul Tornetta, III, MD (c-Lippincott; a,c,e-Smith + Nephew); Brian Puskas, MD (n);Kevin Wang (n);
Boston University Medical Center, Boston, Massachusetts, USA
Introduction: Once the diagnosis of compartment syndrome (CS) in association with tibial fracture is made, a 4-compartment release is typically performed. However, the medial incision and release of the posterior compartments are not without independent morbidity, particularly if the fracture is proximal or involves the plateau. Our purpose is to report on a prospective series of patients in whom an algorithm was used to attempt to avoid releasing the posterior compartments, and the safety of such a practice.
Methods: At one trauma center, patients diagnosed with a CS after tibial fracture were managed with a single protocol. Once the diagnosis was made, patients were brought emergently to the operating room for treatment. A standard anterior and lateral compartment release via a full-length lateral incision and separate fascial incisions was performed. The superficial and deep posterior compartments were then measured using a portable device (Stryker) with the heel resting on a bolster. Using the preoperative diastolic blood pressure, a ΔP <30 was considered to be a positive finding warranting a separate medial incision for release of the posterior compartments. If the ΔP was ≥30, the posterior compartments were not released. After bony stabilization, the posterior compartment pressures were again measured prior to leaving the operating room. Patients were followed every 2 hours on the floor by the orthopaedic residents. Repeat compartment pressure (CP) measurements were taken if their symptomatology changed or if the patient was obtunded. Follow-up by the orthopaedic attending included a careful examination for any sequelae of CS.
Results: A consecutive series of 38 patients (29 male, 9 female patients) of mean age 37 years (range, 18-70) with 9 open, 3 gunshot wounds, and 26 closed tibial shaft (25) or plateau (13) fractures was managed by one surgeon for CS using this protocol. One patient with an isolated posterior CS was excluded. The other 37 had clinical symptoms or CPs consistent with anterior compartment involvement. 21 of 37 patients (57%) had signs or pressures suggesting posterior compartment involvement, of whom 16 had preoperative pressure measurements with an average CP of 41 mm Hg and an average ΔP of 38. After full-length release of the anterior and lateral compartments, only 3 of 37 (8%) required a posterior release for a ΔP of < 30mm Hg. The lowest ΔP in the posterior compartments of the remaining 34 patients averaged 59 (range, 32-86). The CPs in the superficial and deep compartments decreased by 22 mm Hg and 24 mm Hg, respectively, after the anterolateral release for the 16 patients with preoperative values to compare with. None of the patients who had only an anterolateral release developed sequelae of a missed posterior CS.
Discussion and Conclusion: While the anterior compartment is most commonly affected after tibial fracture, once the diagnosis of CS is made, it is considered safest to release all four leg compartments. However, release of the posterior compartments is not without morbidity, particularly if done via a medial incision. We describe a protocol of anterior and lateral release followed by a posterior release only if the ΔP indicates the presence of a posterior CS. 34 of 37 patients in this consort (92%) did not require a 4-compartment release and did not develop sequelae of a missed posterior CS. Additionally, the average CP of the posterior compartments dropped by an average of 23 mm Hg after the anterolateral release. Although this method of management seems safe, it must be recognized that the personnel to follow these patients on the floor, and the resources to bring the patient back to the operating room if needed for a posterior release were available to the surgeon and that different practice environments must be taken into account when managing CS.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.