Slideshow
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Slide
A closed, displaced midshaft tibia fracture.
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Slide
A closed, displaced midshaft tibia fracture.
A 38-year-old man presents to the emergency department (ED) in an ambulance after sustaining a right leg injury. He was clearing some land and had a log roll onto his leg. X-rays taken in the ED show a closed, displaced midshaft tibia fracture (Figures 1 and 2). He was placed in a posterior long leg splint and admitted for intramedullary nail fixation the next day. However, in the middle of the night the patient began to complain of excruciating calf pain that was increasing despite additional intravenous pain medication given during the last few hours. You examine the patient with the splint off and note firm compartments of the right lower leg and severe pain with passive dorsiflexion of the ankle. You suspect compartment syndrome and decide to measure the lower extremity compartments.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
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The lower extremity nerves, muscles, and blood vessels are grouped into 4 compartments surrounded by fascial tissue. The fascia holds the 4 compartments together, including the anterior, lateral, superficial posterior, and deep posterior compartments. The fascial tissue has limited expansion potential as each compartment is wrapped tightly. Traumatic injuries and bleeding can cause the compartments to swell, and without room to expand the pressure within the compartments can elevate. When compartment pressures increase to dangerous levels the vascular and nerve supply to the distal leg can be compromised. Without distal perfusion and an adequate blood supply, tissue can begin to die in the foot. Compartment syndrome most commonly occurs with tibial shaft fractures, although rarely seen (occurring in an estimated 2% of tibia fractures). Other causes of compartment syndrome may include bleeding disorders, crush injuries, tight dressings or casts, burns, and overexertion.1,2
It is crucial to recognize compartment syndrome as a surgical emergency. Classic early signs of acute compartment syndrome of the lower extremity include increasing pain out of proportion despite intravenous pain medication and severe pain with passive stretch of the ankle. If the patient’s clinical signs clearly indicate acute compartment syndrome, then emergent fasciotomy should be performed. If the diagnosis remains unclear and other treatments have failed (bivalving or removing a cast or splint, elevation, ice, and intravenous pain medication), then the compartments should be measured. The most common location for compartment syndrome is the anterior compartment, but all 4 compartments should be measured. When measuring the compartments, any measurement in which the diastolic pressure minus the compartment pressure is <30 mm HG indicates compartment syndrome.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Karadsheh M. Compartment syndrome. Available at: http://www.orthobullets.com/trauma/1001/leg-compartment-syndrome (Accessed on August 22, 2017).
- Olsen SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005;13:436-444.
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