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Compartment Syndrome resulting from Tibial Frx

- See: Fasciotomy of the Leg

- Discussion:
    - general discussion of compartment syndrome
    - compartment syndrome following tibia fractures are most common in closed frx (upto 20% of frx) but may also occur
               following open frx;
               - references:
                      - Outcome at 12 to 22 years of 1502 tibial shaft fractures
                      - Compartment syndrome in open tibial fractures.

    - cast immobilization may increase pressure; 
    - compartment pressures measurements:
          - most common finding is isolated elevation in the deep posterior compartment followed by isolated elevation in
                    anterior compartment;
          - be sure to measure pressure in the deep posterior compartment as well as anterior & superficial compartments;
          - note that pressure criteria for compartment syndrome is not met until pressure measurements are in the diagnostic range for
                  more than 2 hours, and note that patients can manifest high compartment pressures without having true compartment
          - references:
                  - The Estimated Sensitivity and Specificity of Compartment Pressure Monitoring for Acute Compartment Syndrome
                  - Intramuscular pressure varies with depth. The tibialis anterior muscle studied in 12 volunteers.
                  - Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the site of the fracture.
                  - Compartment pressures after closed tibial shaft fracture. Their relation to functional outcome.
    - associated factors:
          - cast immobilization may increase pressure;
          - intramedullary nailing:
                - it remains unclear whether IM nailing will increase or decrease compartment pressures, but on occasion the surgeon may
                        find a significant decrease in pressure measurements following nailing; 
               - references:
                        - Compartment syndrome in open tibial fractures.
                        - Compartment syndrome after intramedullary nailing of the tibia.
                        - Predictors of Compartment Syndrome After Tibial Fracture.

- Clinical Presentation:
    - symptoms may not appear for 24 hours after injury;
    - clinical signs include increased pain even after reduction and casting;
    - severe tenderness over the anterior compartment muscles rather than fracture site is an indication of compartment syndrome;
    - silent compartment syndrome:
          - in patients with altered consciousness or with spinal/epidual anesthesia, pain may not be present;
          - in this circumstance, the initial findings may only demonstrate progressive neurologic deficit (sensory and motor);
          - note that irreversible muscle damage may occur after 4-6 hours, after which time the pain of ischemic muscles may diminish or
                be absent;
          - reference:
                - Compartment syndrome without pain!
                - Does PCA delay the diagnosis of compartment syndrome following intramedullary nailing of the tibia?
                - Differences in attitudes to analgesia in post-operative limb surgery put patients at risk of compartment syndrome.
                - Acute compartment syndrome masked by intravenous morphine from a patient-controlled analgesia pump. 
                - The 'silent' compartment syndrome

- Exam:
    - blood pressure:
          - compartment syndrome is potentiated by hypotension;
          - ref: Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome.
    - pain:
          - extreme pain out of proportion to the injury,
          - pain on passive ROM of the fingers or toes (stretch pain of the involved compartment):
          - patient will usually hold injured part in a position of flexion to maximally relax the fascia and reduce pain;
    - pulses:
          - when checking an extremity pulse (such as dorsalis pedis) be sure to occlude the other major artery (posterior tibial artery) so
                    that retrograde flow does not confuse the diagnosis;
          - apply a pulse oximetry monitor to the great toe, and sequentially occlude the posterior tibial and dorsalis pedis pulses;
          - compare pulses to the opposite non injured side (to rule out vascular injury);
     - pallor of the extremity,
     - paralysis,
     - paresthesias (early loss of vibratory sensation);
     - anterior compartment:
             - variable weakness of toe extension;
             - pain on passive toe flexion;
             - diminished sensation in the first web space;
     - posterior compartment:
            - weakness of toe flexion and ankle inversion;
            - pain on passive toe extension (may referr to the back of the leg)
            - diminished sensation over the sole of the foot;
            - ref: The deep posterior compartmental syndrome of the leg.

- Management:
    - note that the definitive diagnosis of compartment syndrome can be made at the time of surgery;
          - diagnosis is confirmed if:
                  - escape of muscles occurs at fasciotomy or if color change in the muscles
                  - muscle necrosis was found intraoperatively
          - diagnosis is partially excluded if fasciotomy wounds can be closed primarily at 48 hours
    - fasciotomy
          - normally the lateral fasciotomy incision is made halfway between the tibia and fibula;
          - w/ a difficult fracture reduction, consider making the incision slightly closer to the tibia so that the fracture site can be palpated
                    and bone holding clamps can be applied;
          - if cast has been applied, it should be bivalved immediately;
          - w/ all open fractures of grade II or above, or those w/ crushing component consider a limited fasciotomy
    - reperfusion injury: should be considered;

    - delayed fracture healing:

           - reference:
                  - What is the effect of compartment syndrome and fasciotomies on fracture healing in tibial fractures?
    - equinovarus:
common sequelae of compartment syndrome;
           - anterior/posterior compartment syndrome:
intact peroneus longus overpowers weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal,
                           cavus, and hindfoot varus;
                 - peroneus longus transfer to the dorsolateral midfoot reduces the first metatarsal plantar flexion forces, and may assist ankle
                - also my require achilles tendon lengthening;
           - anterior and lateral compartment syndrome:
                - posterior tibialias remains intact and is the deforming force;
                - posterior tibial transfer to midfoot will address the drop foot deformity;
           - reference: 
                   - Tibial compartment syndrome and the cavovarus foot.
                   - Cavus deformity of the foot after fracture of the tibial shaft.  

- Children:
       - hight incidences in teenagers involved in MVA
       - look for delayed compartment syndrome;
       - references:
              - Acute Traumatic Compartment Syndrome of the Leg in Children: Diagnosis and Outcome
              - The acute compartment syndrome following fractures of the lower leg in children.
              - Acute compartment syndrome in children and teenagers with tibial shaft fractures: incidence and multivariable risk factors.
              - Do minimally displaced, closed tibial fractures in children need monitoring for compartment syndrome?
              - The incidence of compartment syndrome after flexible nailing of pediatric tibial shaft fractures
              - Acute compartment syndrome after intramedullary nailing of isolated radius and ulna fractures in children.

Fracture of the tibia complicated by acute compartment syndrome.
Compartment syndrome in the well leg resulting from fracture-table positioning.
Skeletal stabilization for tibial fractures associated with acute compartment syndrome.
Does patient controlled analgesia delay the diagnosis of compartment syndrome following intramedullary nailing of the tibia?
Differences in attitudes to analgesia in post-operative limb surgery put patients at risk of compartment syndrome.
Compartment syndrome in tibial fractures.
Compartment Syndrome After Low-Energy Tibia Fractures Sustained During Athletic Competition
Stiffness and Thickness of Fascia Do Not Explain Chronic Exertional Compartment Syndrome
Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy.