Extensor retinaculum syndrome after distal tibial fractures: anatomical basis

Abstract

Fractures of the distal extremity of the tibia include physeal injuries among teenagers and more complex fractures among adults. Displacement causes the compression of the muscles located between the distal tibia and the superior extensor retinaculum (SER). Among the muscles of anterior compartment of the leg, the extensor hallucis longus (EHL) is particularly vulnerable due to the amount of muscle fibers extending under the SER. Consequently, a partial anterior compartment syndrome could result, affecting only the distal portion located under the SER. In clinical practice, Mubarak measured the intramuscular pressure isolated under the SER and suggested the physio-pathological hypothesis of a compression of distal muscle fibers. The aim of this study is to compare the ratios of anterior compartment muscle fibers extending under the SER. Twenty legs were dissected in order to study how much of these muscles extend under the SER, their passages possibly dividing into two of the SER, as well as their vascularization and their innervation. On the last seven legs, the engagement of the muscles were measured in the spontaneous position and with a dorsal flexion of 0 degrees . The posterior muscle fibers of this compartment always descend lower than the anterior fibers. EHL muscle fibers and those of the inconsistent fibularis tertius always extend under the retinaculum, unlike those of the tibialis anterior and of the extensor digitorum longus. The EHL muscle extends under the SER more than the other muscles. Its posterior fibers are longer when this muscle goes through a dividing into two of the retinaculum. Its vascularization seems lesser, which could explain why this muscle tends to suffer more. The deep fibular nerve innervates the anterior compartment of the leg, yet no nerve branches can be found under the upper edge of the retinaculum. In all cases, the muscle fibers do not extend as much under the SER in a 0 degrees of dorsal flexion. This anatomical study allows us to explain why the EHL is more likely to suffer from this partial compartment syndrome and confirms that when the latter occurs it is necessary, in all cases, to do emergency surgery opening the distal crural fascia and necessarily including the SER.