Trauma Case 61COMPARTMENT SYNDROME

You are the on-call orthopaedic registrar and you are asked to see a young man who has been brought to the emergency department after a direct collision with another player on the football pitch.

1.    This is his radiograph, which shows his only injury. Can you tell me what is going on here and how you would manage this in the first instance?

This is an AP and lateral radiograph of a right tibia showing a displaced mid- diaphyseal tibial fracture. I would make a full clinical assessment taking a history and performing a full examination with particular reference to any open wounds. I would also perform and record a neurovascular examination and specifically look to exclude compartment syndrome. If this was all satisfactory, I would ensure that the patient had adequate analgesia before splinting them in an above knee backslab. I would admit them to the ward area. I would plan to manage this fracture with intramedullary nailing and I would mark and consent the patient for this to be per- formed on the next routine trauma list.

2. You are called to reassess the patient on the ward just after 1 a.m. because he has been complaining of pain and is requiring considerable amounts of opioid anal- gesia. What do you think might be going on and how would you proceed?

This presentation is typical of compartment syndrome, which can be associated with tibial fractures. I would reassess the patient. The predominant presenting fea- ture of compartment syndrome is pain out of proportion to that which would be expected from the injury alone. Paresthesiae, pallor, paralysis and pulselessness may

all be additional late signs. Compartment syndrome is a clinical diagnosis but if there is doubt as to the diagnosis, I might consider compartment pressure monitor- ing. Increased opioid consumption is a warning sign. Pain is exacerbated by pas- sive stretch of the muscles in the affected compartment, in this case, the extensor hallucis longus, toe extensors and tibialis anterior. Having confirmed the diagnosis clinically I would consent and mark the patient to undergo emergent fasciotomies and intramedullary nailing of the fracture at the same sitting.

3.    Can you tell me how you would perform your fasciotomies and where you would place your incisions?

I would perform a two-incision four-compartment fasciotomy. In an appropriately marked and consented patient, I would position the patient on a radiolucent table suitable for subsequent freehand intramedullary nailing. I would initially place a sandbag under the ipsilateral hip to roll the leg into slight internal rotation and I would make my lateral incision first.

The lateral skin incision is placed halfway between the tibial crest and the subcuta- neous surface of the fibula so that is anterior to the fibula and it is an extensile incision along the length of the leg. I would ‘spread’ through fat onto the fascial layer, being careful not to injure the superficial peroneal nerve, although if it is not apparent I will not specifically look for it or dissect it out. I would expect to find it 5–10 cm proxi- mal to the lateral malleolus. I feel for the lateral intermuscular septum to identify the demarcation between the anterior and lateral compartments and then retract the skin flaps to incise the fascial layer longitudinally over each compartment. I would then inspect and palpate to ensure there are no taut bands of fascia remaining. The diagno- sis is often confirmed at the time of surgery by a tight compartment, bulging muscle or sometimes apparent muscle necrosis. I would assess the muscle compartments for colour, consistency, capacity to bleed and contractility.

I would then move to the medial side and I would pack the lateral wounds with saline-soaked swabs and ask for the sandbag to be removed. I would site my medial skin incision 1 cm posterior to the medial border of the tibia aiming to protect per- forating vessels and to come anterior to the posterior tibial artery. Again, this is an extensile incision, along the length of the leg, and I would aim to leave an adequate skin bridge of at least 7 cm between incisions. I would dissect down to the fascial layer and divide this in the line of the skin incision to decompress the superficial posterior compartment. I would then retract or bluntly dissect the superficial com- partment muscles off the deep compartment to expose the fascia overlying the deep compartment and I would incise this as well, releasing the muscle completely.

Importantly, the wounds are not closed and after the tibial fracture has been treated with nailing, the wounds are dressed with a negative pressure dressing. The patient is brought back to the operating theatre for wound inspection, debridement if required and possible wound closure at 48 hours as a planned procedure with plastic surgeons in attendance. If early closure is not possible at the first inspection, I would plan to undertake a second inspection at a further 48 hours with a plastic surgeon and be prepared to proceed with split skin grafting if necessary. The patient remains on intravenous antibiotics until the wounds are closed.

4. Assuming the diagnosis was delayed for several days after tibial nailing in the same patient, how would you manage this?

This is a difficult decision. There is very little evidence to guide the management of a delayed diagnosis of compartment syndrome. In this situation, the aim is to