Acute compartment syndrome in tibial diaphyseal fractures.
ABSTRACT We reviewed 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. Thirteen had undergone continuous monitoring of the compartment pressure and the other 12 had not. The average delay from injury to fasciotomy in the monitored group was 16 hours and in the non-monitored group 32 hours (p < 0.05). Of the 12 surviving patients in the monitored group, none had any sequelae of acute compartment syndrome at final review at an average of 10.5 months. Of the 11 surviving patients in the non-monitored group, ten had definite sequelae with muscle weakness and contractures (p < 0.01). There was also a significant delay in tibial union in the non-monitored group (p < 0.05). We recommend that, when equipment is available, all patients with tibial fractures should have continuous compartment monitoring to minimise the incidence of acute compartment syndrome.
- Acta chirurgica Scandinavica 04/1961; 121:56-66.
- [show abstract] [hide abstract]
ABSTRACT: The two basic research tools developed to measure tissue fluid pressure (wick catheter) and osmotic pressure (colloid osmometer) have undergone extensive validation and refinement over the past 20 years. Using these techniques, basic science investigations were undertaken of edema in Amazon reptiles, pressure-volume relations in animals and plants, adaptive physiology of Antarctic penguins and fishes, edema in spawning salmon, tissue fluid balance in humans under normal conditions and during simulated weightlessness, and orthostatic adaptation in a mammal with high and variable blood pressures--the giraffe. Following and sometimes paralleling this basic research have been several clinical applications related to use of our colloid osmometer and wick technique. Applications of the osmometer have included insights into (a) reduced osmotic pressure of sickle-cell hemoglobin with deoxygenation and (b) reduced swelling pressure of human nucleus pulposus with hydration or certain enzymes. Clinical uses of the wick technique have included (a) improvement of diagnosis and treatment of acute and chronic compartment syndromes, (b) elucidation of tissue pressure thresholds for neuromuscular dysfunction, and (c) development of a better tourniquet design for orthopaedics. This article demonstrates that basic research tools open up areas of basic, applied, and clinical research.Journal of Orthopaedic Research 02/1989; 7(6):902-9. · 2.88 Impact Factor
VOL. 78-B, NO. 1, JANUARY 199695
M. M. McQueen, FRCS Ed(Orth), Consultant Orthopaedic Surgeon
J. Christie, FRCS, Consultant Orthopaedic Surgeon
C. M. Court-Brown, MD, FRCS Ed(Orth), Consultant Orthopaedic
Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh NHS Trust,
Lauriston Place, Edinburgh EH3 9YW, UK.
©1996 British Editorial Society of Bone and Joint Surgery
ACUTE COMPARTMENT SYNDROME IN
TIBIAL DIAPHYSEAL FRACTURES
M. M. MCQUEEN, J. CHRISTIE,
From the Royal Infirmary of Edinburgh, Scotland
C. M. COURT-BROWN
acute compartment syndrome. Thirteen had
undergone continuous monitoring of the compartment
pressure and the other 12 had not.
The average delay from injury to fasciotomy in the
monitored group was 16 hours and in the
non-monitored group 32 hours (p < 0.05). Of the 12
surviving patients in the monitored group, none had
any sequelae of acute compartment syndrome at final
review at an average of 10.5 months. Of the 11
surviving patients in the non-monitored group, ten
had definite sequelae with muscle weakness and
contractures (p < 0.01). There was also a significant
delay in tibial union in the non-monitored group
(p < 0.05).
We recommend that, when equipment is available,
all patients with tibial fractures should have
continuous compartment monitoring to minimise the
incidence of acute compartment syndrome.
e reviewed 25 patients with tibial diaphyseal
fractures which had been complicated by an
J Bone Joint Surg [Br] 1996;78-B:95-8.
Received 12 January 1995; Accepted after revision 27 June 1995
Acute compartment syndrome is a potentially devastating
complication of tibial diaphyseal fractures, and early diag-
nosis is important for the prevention of disability. In the
past, diagnosis has depended on the clinical symptoms and
signs, including pain which is more severe than would be
expected from the fracture. Pain may be an unreliable
indication; it can be very variable (Eaton and Green 1975;
Whitesides et al 1975; Matsen and Krugmire 1978), and
may be absent in an established acute compartment syn-
drome associated with nerve injury (Holden 1979; Wright,
Bogoch and Hastings 1989), or minimal in the deep poster-
ior compartment syndrome (Matsen and Clawson 1975;
Matsen and Krugmire 1978). Sensory symptoms and signs
are often the first indication of nerve ischaemia, and if a
motor deficit develops full recovery is rare (DeLee and
Stiehl 1981; Rorabeck 1984; Schwartz et al 1989; Willis
and Rorabeck 1990).
Delay in diagnosis is often due either to inexperience and
lack of suspicion, or to an indefinite and confusing clinical
presentation. Delay in treatment can be catastrophic leading
to contracture, infection and occasionally amputation.
McQuillan and Nolan (1968) reported four of 15 cases of
acute compartment syndrome in which the diagnosis was
delayed by more than 24 hours; because of this all four
patients had persistent motor and sensory deficits. This
warning is repeated in many other reports (Matsen and
Clawson 1975; Rorabeck and Macnab 1976; Sheridan and
Matsen 1976; Matsen and Krugmire 1978; DeLee and
Stiehl 1981; Rorabeck 1984). The critical delay is con-
sidered to vary from 6 to 24 hours.
Current opinion is that there is a variety of indications
for compartment pressure monitoring. These include an
unconscious patient (Whitesides et al 1975; Gelberman et
al 1981; Hargens et al 1989; Schwartz et al 1989), a patient
difficult to assess, such as a young child (Whitesides et al
1975; Willis and Rorabeck 1990), patients with equivocal
symptoms and signs (Gelberman et al 1981), particularly in
the presence of concomitant nerve injury (Whitesides et al
1975; Wright et al 1989) and those with multiple injuries
(Bourne and Rorabeck 1989; Schwartz et al 1989; Willis
and Rorabeck 1990). Both Shereff (1990) and Myerson
(1991) state that the clinical diagnosis of compartment
syndrome in the foot is so unreliable that compartment
pressure monitoring is essential.
Others consider that routine pressure monitoring may be
unnecessary because of the infrequent occurrence of com-
partment syndrome, the fact that pressure measurements are
cumbersome, and because the need for fasciotomy is clini-
cally apparent (Rollins, Bernhard and Towne 1981).
Despite this statement five of the patients in the study of
Rollins et al had sequelae of acute compartment syndrome
because the diagnosis had been delayed.
We have reviewed the effect of compartment pressure
monitoring on the outcome of tibial diaphyseal fractures
complicated by acute compartment syndrome.
PATIENTS AND METHODS
From January 1988 to July 1992 a total of 25 patients with
tibial diaphyseal fractures complicated by acute compart-
ment syndrome were admitted to the Orthopaedic Trauma
Unit of the Royal Infirmary of Edinburgh. There were 23
male and two female patients with an average age of 28
years (15 to 83). Sixteen had sporting injuries and seven
had been involved in road-traffic accidents. One had had a
simple fall and one had fallen from a height of 30 feet.
Twenty-three of the fractures were closed and two were
open and their classifications are shown in Table I. Most of
the closed fractures were in Tscherne grades 1 or 2, which
is a similar distribution to that of all tibial diaphyseal
fractures in Edinburgh (Court-Brown, Christie and
McQueen 1990). Seventeen fractures were treated by intra-
medullary nailing and eight by external fixation.
Six patients had additional injuries, and two of them had
fractures of the ipsilateral femur, which implies major limb
Pressure monitoring was at the discretion of the surgeon
in charge. A slit catheter (Rorabeck et al 1981) was placed
in the anterior compartment. The clinical diagnosis of acute
compartment syndrome was made depending on the pres-
ence of some or all of the clinical indications (severe pain,
stretch pain, sensory deficit, motor deficit), a differential
pressure (?P) of less than 30 mmHg between the diastolic
and compartment pressures (McQueen and Court-Brown
1996) or a combination of both clinical and pressure
Twenty-three patients had measurement of the compart-
ment pressure: in 13 this started within eight hours of
injury. In ten patients it began only immediately before
fasciotomy to confirm the clinical diagnosis. Two had no
monitoring. There were therefore 12 patients who did not
have early continuous monitoring.
Twenty-four patients had double incisions with fascio-
tomy of all four compartments. One patient had fascio-
tomies of the anterior and lateral compartments only with
no monitoring of the superficial or deep posterior compart-
ments. Twenty-four hours later, exploration prompted by
pain and stretch pain of the toe flexors revealed necrosis of
the muscles of the deep posterior compartment.
Two patients died from other injuries leaving 23 avail-
able for review after a mean of 10.5 months (4 to 32). The
time to bone union was assessed by one observer (CCB)
with no knowledge of whether monitoring had been used.
Bone union was defined as the ability of the patient to bear
weight without pain on the unprotected leg and by the
presence on radiographs of bridging callus.
Statistical analysis used the Wilcoxon rank-sum test, the
chi-squared test and multiple logistic regression.
The average delay from admission to fasciotomy was 23
hours (4 to 80). In the 12 patients who had late or no
monitoring the delay averaged 32 hours (4 to 80). In the 13
who had early monitoring the average delay was 16 hours
(4 to 28). The difference is statistically significant (Wilcox-
on rank-sum test, p < 0.05). The average delay from frac-
ture manipulation and fixation to fasciotomy in the
non-monitored group was 24 hours (4 to 64); in the mon-
itored group it was 7 hours (0 to 24).
Four patients in the monitored group had delayed onset
of the compartment syndrome at 14, 16, 18 and 24 hours,
respectively after surgery, all being diagnosed by pressure
monitoring. In two patients there was a clear association
between reduction and fixation of the fracture and a rise in
pressure to critical levels. One had been treated by intra-
medullary nailing and the other by closed external
One patient in the non-monitored and one patient in the
monitored group died from their other injuries, leaving 11
and 12 patients respectively in the two groups. In the
former, 10 of the 11 patients had continuing problems
secondary to their acute compartment syndrome; there was
muscle weakness in six, muscle contractures in three and
soft-tissue infection in one. One patient with muscle weak-
ness also had a permanent sensory deficit.
None of the 12 patients in the early monitored group had
any sequelae of acute compartment syndrome, and the
difference between groups is statistically significant (chi-
squared test = 10.36, p < 0.01; Table II). As regards the
severity of the original injury the Wilcoxon rank-sum test
showed no significant differences between the two groups
for either fracture type or the number of compartments
96M. M. MCQUEEN,J. CHRISTIE,C. M. COURT-BROWN
THE JOURNAL OF BONE AND JOINT SURGERY
Table I. Classification of the tibi-
al fractures complicated by acute
compartment syndrome accord-
ing to Oestern and Tscherne
(1984) and Gustilo and Anderson
Table II. Complication rates for monitored and non-monitored patients
with acute compartment syndrome after tibial fracture
ComplicationsNo complications p value
patients (n = 12)
patients (n = 11)
involved. Multiple logistic regression showed that the use
of early monitoring still predicted fewer complications
(p < 0.05) even after adjustment for delay and the number
of compartments involved.
The average time to union in the 23 patients was 21
weeks (Table III). The 11 Tscherne grade-1 fractures had a
mean time to union of 19 weeks (9 to 42) and the 7
Tscherne grade-2 fractures united at a mean of 23 weeks
(12 to 29). For the monitored fractures mean union was at
17 weeks (9 to 26) and for the non-monitored fractures 25
weeks (13 to 42). Three fractures in the non-monitored
group required further surgery to achieve union, but no
fractures in the monitored group were considered to show
delayed union. The Wilcoxon rank-sum test showed that
the use of early compartment monitoring had a significant
influence in reducing time to union (p < 0.05), as did a
shorter time to fasciotomy (p < 0.05).
In all 25 patients the anterior compartment was involved.
Six of these had positive surgical findings in all four
compartments, three had involvement of the anterior and
the lateral compartments and four of the anterior and deep
posterior compartments. Twelve had isolated involvement
of the anterior compartment.
During the period of the study, 622 tibial diaphyseal
fractures were treated in our Orthopaedic Trauma Unit,
giving an incidence of acute compartment syndrome after
tibial fracture of 4%. Of these, 166 were open tibial
diaphyseal fractures and the incidence of acute compart-
ment syndrome in these was 1.2%. The difference in
incidence between closed and open tibial fractures is not
significant (chi-squared test, p < 0.1).
There were 342 tibial fractures in patients aged 35 years
or younger and 280 in those aged over 35 years; 22 of the
cases of acute compartment syndrome were in the younger
group and only three in the older group. All three of the
older patients had multiple injuries and one was hypo-
tensive. There was a significantly higher risk of acute
compartment syndrome in the younger group (p < 0.01,
chi-squared). This was not related to the incidence of high-
energy injury; 43% of the younger group had high-energy
injuries compared with 55% of the older group.
Our results show that the use of early continuous compart-
ment monitoring significantly reduced the delay to fascio-
tomy and therefore the long-term sequelae of acute com-
partment syndrome. The absence of complications in the
early monitored group clearly indicates its advantages.
It is widely accepted that delay is disastrous. McQuillan
and Nolan (1968) considered that delay to fasciotomy was
the only cause of failure in their series, and this view has
been reinforced by others (Matsen and Clawson 1975;
Sheridan and Matsen 1976; Gelberman et al 1981; Ror-
abeck 1984; Schwartz et al 1989). The use of compartment
monitoring heightens awareness of the possibility of the
syndrome and confirms clinical findings. It also signifi-
cantly reduces delay to fasciotomy and the incidence of
complications. We therefore recommend that all tibial frac-
tures, when equipment is available, should have continuous
It was a surprise to find that the use of monitoring alone
has a significant effect on the outcome even when the
effects of delay and severity of fracture are eliminated. One
explanation may be that the patients who were monitored
tended to be those treated by orthopaedic trauma special-
ists; the direct influence of monitoring on outcome may be
a reflection of awareness of the problem and better
Firm criteria for the patient ‘at risk’ would help to allow
selective use of compartment monitoring, which may be a
limited resource in many centres. We have shown that
young patients with tibial fractures are at a higher risk: in
our series 7% of this group developed the syndrome as
against 1% in the older age group. It is possible that this is
due to the relatively large muscle volume in young
We found a significant delay in bone union in fractures
which were not monitored; all these injuries had longer-
term sequelae and therefore by implication significant mus-
cle necrosis. These patients may have lacked the normal
extraosseous blood flow derived from the muscle (Gothman
1960), which supplies developing callus. This clinical
observation supports our previous retrospective study
(Court-Brown and McQueen 1987) and is confirmed by
experimental work which demonstrated both a reduction in
bone blood flow (McQueen and Fleming, unpublished data)
and a delay in bone union (McQueen et al, unpublished
data) after acute compartment syndrome.
It is difficult to define the exact time of onset of acute
compartment syndrome; the time of injury is not neces-
sarily the time of onset of the syndrome. This is demon-
strated in the four patients in whom onset occurred from 14
to 24 hours after surgery. Two patients with a rise in
compartment pressure soon after fracture reduction and
fixation also serve to illustrate the ‘finger-trap’ phenomen-
on (Matsen and Clawson 1975).
In open fractures, we found a 1.2% incidence of acute
compartment syndrome. This is lower than the incidence of
6% quoted by DeLee and Stiehl (1981) and of 9.1% quoted
by Blick et al (1986). The latter made the diagnosis on
pressures of 30 mmHg or more and may have overdiag-
nosed. It is clear that the belief of Rorabeck and Macnab
(1976) that the presence of an open fracture prevents a
97ACUTE COMPARTMENT SYNDROME IN TIBIAL DIAPHYSEAL FRACTURES
VOL. 78-B, NO. 1, JANUARY 1996
Table III. Union rates (weeks; range) for monitored and non-monitored
patients with acute compartment syndrome after tibial fracture
Tscherne grade AllMonitoredNon-monitored
1 (n = 11)19 (9 to 45)14 (9 to 16)29 (13 to 42)
2 (n = 7)23 (12 to 29)20 (12 to 26)26 (18 to 31)
significant rise in intracompartmental pressure is mistaken.
Fasciotomy of all four compartments is always required
in the absence of compartment monitoring to avoid serious
complications. The need for this is illustrated by the
patients who had decompression initially only of the anter-
ior and lateral compartments and 24 hours later required
excision of the deep posterior compartment.
We found that the anterior compartment is consistently
affected in tibial fractures complicated by acute compart-
ment syndrome. Sheridan and Matsen (1976) also reported
that the anterior compartment was most commonly
involved. Gershuni et al (1987) found that 30 of 32 tibial
fractures complicated by an acute compartment syndrome
had anterior compartmental involvement, but they did not
use pressure measurements. The monitoring of all four
compartments is cumbersome and it seems unlikely that the
anterior compartment will not be involved in an acute
compartment syndrome. The anterior compartment should
be monitored routinely; other compartments need be inves-
tigated only if there is clinical suspicion of involvement.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
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