Acute Compartment Syndrome in the Treatment of Tibial Fractures: Clinical and Radiological Risk Factors

Abstract

Introduction: This Privat Docent thesis collects the author's recent retrospective study results on potential clinical and radiological risk factors for the occurrence of acute compartment syndrome in the treatment of tibia fractures. Clinical evaluation of acute compartment syndrome and intra-compartmental pressure measurements are not completely reliable. This might lead to difficulties in diagnosing or ruling out acute compartment syndrome, especially in patients with equivocal clinical signs and those with loco-regional anesthesia, intubated, sedated or obtunded. Alternative predictors of acute compartment syndrome need to be determined. The objective of the author’s research was therefore to analyze the relation between key demographic, injury-related, clinical and radiographic factors in patients with proximal tibia, diaphyseal tibia and distal tibia fractures and the subsequent development of acute compartment syndrome. Recent publications and current research: -Association between open tibia fractures and acute compartment syndrome (retrospective cohort study, 711 consecutive adult patients with 725 tibia fractures): this study highlighted an association between open Gustilo type 2 and 3 lesions and occurrence of acute compartment syndrome in proximal intra-articular fractures only; there was no association with closed or any type of open fractures in extra-articular fractures, and there were not enough acute compartment syndrome cases among distal intra-articular fractures to draw conclusions. -Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial plateau fractures (retrospective cohort study, 265 consecutive adult patients with 269 intra-articular tibial plateau fractures): two parameters related to the occurrence of acute compartment syndrome in tibial plateau fractures were pointed out, namely the presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification. -Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures (retrospective cohort study, 270 consecutive adult patients with 273 tibial shaft fractures): one radiological parameter related to the occurrence of acute compartment syndrome was pointed out: this parameter was a longer distance between the center of the fracture and the talar dome, in other words a fracture located more proximally within the tibia. Diaphyseal tibial fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries were also at higher risk of acute compartment syndrome. Radiographic signs of higher fracture displacement were not associated with ACS occurrence. -Current research – Association between muscle mass surrounding the fracture site and occurrence of acute compartment syndrome in extra-articular fractures of the tibia: this research is aimed at refining the conclusion of the previous study, in which the most powerful acute compartment syndrome predictor in tibial shaft fractures was the distance between the talar dome and the center of the tibial shaft fracture, meaning that a more proximal fracture was more prone to be associated with the development of acute compartment syndrome. The explanation for this finding was that a fracture surrounded by a larger muscle mass (proximal diaphysis) may result in a higher amount of energy transferred to the soft tissues and potentially to acute compartment syndrome development. This ongoing research consists of analyzing acute compartment syndrome rate and muscle mass associated to each eight arbitrarily pre-defined isometric tibia segments in order to evaluate a potential correlation between both these factors. Conclusions and perspective for future research: Early recognition of injuries at risk of acute compartment syndrome is essential in the screening and treatment of tibia fractures, especially by intubated, sedated or obtunded patients. Author’s recent publications were able to demonstrate different risk factors for the occurrence of acute compartment syndrome during the treatment of tibia fractures. When one or more risk factor is present, regular clinical examinations and/or repeated or continuous intra-compartmental pressure measurements should be performed before and after the surgery to monitor soft tissue condition, even if the initial assessments were unremarkable regarding the eventual presence of acute compartment syndrome. All the factors highlighted by the author in predicting the occurrence of acute compartment syndrome would need to be confirmed and refined by larger studies.