Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures: a retrospective cohort study

Abstract

Background: The purpose of this study was to evaluate the association between epidemiological, clinical and radiographic factors of patients with tibial shaft fractures and the occurrence of acute compartment syndrome. Methods: 270 consecutive adult patients sustaining 273 tibial shaft fractures between January 2005 and December 2009 were included in this retrospective cohort study. The outcome measure was acute compartment syndrome. Patient-related (age, sex), fracture-related (high-vs. low-energy injury, isolated trauma vs. polytrauma, closed vs. open fracture) and radiological parameters (AO/OTA classification, presence or absence of a noncontiguous tibial plateau or pilon fracture, distance from the centre of the tibial fracture to the talar dome, distance between tibial and fibular fracture if associated, and angulation, translation and over-riding of main tibial fragments) were evaluated regarding their potential association with acute compartment syndrome. Univariate analysis was performed and each covariate was adjusted for age and sex. Finally, a multivariable logistic regression model was built, and odds ratios and 95% confidence intervals were obtained. Statistical significance was defined as p < 0.05. Results: Acute compartment syndrome developed in 31 (11.4%) cases. In the multivariable regression model, four covariates remained statistically significantly associated with acute compartment syndrome: polytrauma, closed fracture, associated tibial plateau or pilon fracture and distance from the centre of the tibial fracture to the talar dome ≥15 cm. Conclusions: One radiological parameter related to the occurrence of acute compartment syndrome has been highlighted in this study, namely a longer distance from the centre of the tibial fracture to the talar dome, meaning a more proximal fracture. This observation may be useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients). However, larger studies are mandatory to confirm and refine the prediction of acute compartment syndrome occurrence. Radiographic signs of significant displacement were not found to be correlated to acute compartment syndrome development. Finally, the higher rate of acute compartment syndrome occurring in tibial shaft fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries must raise the level of suspicion of any surgeon managing multiply injured patients.

Association between open tibia fractures and acute compartment syndrome: a retrospective cohort study

“…There were not enough ACS cases (four) among distal intra-articular fractures to draw conclusions (Table 3). The ACS occurrence rates found in this study fall within previously reported rates in the literature, which ranged from 0.7-12% for tibial plateau fractures (even as high as 53% for some higher-energy subgroups) [8][9][10][11][12][13][14][15][16], from 3-11.5% for tibial shaft fractures [8,12,13,[17][18][19], and from 2-12.5% for pilon tibial fractures [8,13,20]. For this reason, it can be assumed that the study cohort closely represents the habitual spectrum of tibia fractures, and that its results might be generalized to most tibia fracture patients.…”

“…Indeed, our results showed that distal extra-articular fracture might be a protecting factor against ACS occurrence, when compared to a more proximal location. This nding might be explained by the fact that the distal tibia is surrounded by a less bulkier muscle mass, and that the energy released during trauma is transmitted into tendinous soft tissues rather than muscle, thus less likely leading to the potential development of ACS [19].…”

“…Every patient was clinically examined focusing on ACS signs and symptoms at admission and during every preoperative and postoperative visit, as well as during surgery. Using the same method as previously published [11,19], monitoring of intra-compartmental pressure (ICP) was not routinely used to establish ACS diagnosis, but only in selected patients with equivocal clinical signs and those intubated, sedated or obtunded [23][24][25]. Four compartments fasciotomy was performed when patients had clinical signs of ACS and/or when pathological ICP values were measured (ICP > 30 mmHg or a difference < 30 mmHg between diastolic blood pressure and ICP) [18,24,26,27].…”

“…They were then strati ed into three groups: proximal intra-articular fractures (AO/OTA 41B and C), extra-articular fractures (AO/OTA 41A2 and A3, 42 and 43A) and distal intra-articular fractures (AO/OTA 43B and C). Additionally, the presence or absence of an associated second contiguous skeletal injury was determined, as this variable was highlighted as a risk factor for ACS occurrence in tibial plateau and tibial shaft fractures in two recent publications [11,19]. A second contiguous skeletal injury was de ned as followed: 1) for proximal tibia fractures, it was either a tibial shaft or pilon fracture (AO/OTA 42 or 43) [22], or a dislocation of both medial and lateral femoro-tibial joint lines [11]; 2) for tibial shaft fractures, it was a second fracture complex located either in the proximal or distal metaphysis (AO/OTA 41 or 43) [22]; for pilon tibial fractures, it was a second fracture complex located either in the proximal metaphysis or in the shaft (AO/OTA 41 or 42) [22].…”

“…The energy transmitted to the limb during trauma may also lead to soft-tissue lesions, including skin lacerations (open fractures) and acute compartment syndrome (ACS) [2,3,[5][6][7]. Reported risks of ACS are as high as 12% for overall tibial plateau fractures (even 53% for some high-energy subtypes) [8][9][10][11][12][13][14][15][16], and as high as 11.5% for tibial shaft fractures [8,12,13,[17][18][19]. The literature is poor about the association of pilon tibial fractures with ACS, and the risk seems relatively low, with two papers reporting an occurrence rate of 2% and another of 12.5% [8,13,20].…”