Which tibial fractures require compartment syndrome checks?

From the Guidelines

All tibia fractures require compartment syndrome checks due to the high risk of this serious complication. Compartment syndrome occurs when increased pressure within a muscle compartment compromises circulation and nerve function. For tibia fractures, compartment checks should be performed every 2-4 hours for the first 24-48 hours post-injury or post-surgery, as recommended by the Association of Anaesthetists 1. These checks involve assessing the 5 P's: pain out of proportion to injury (especially with passive stretching), paresthesia (numbness/tingling), pallor, paralysis, and pulselessness. Pain and paresthesia are early signs, while the others are late findings. High-energy injuries, comminuted fractures, and crush injuries carry higher risk, as noted in the guidelines for the acute care of severe limb trauma patients 1.

Some key points to consider when assessing for compartment syndrome include:

• The use of objective scoring charts is recommended to identify the signs and symptoms of ACS 1
• The equipment necessary to measure intracompartmental pressure should be available on wards caring for patients at risk of ACS 1
• Staff should be trained in the use of intracompartmental pressure measurement and in the recognition of ACS 1
• Intracompartmental pressure measurements may be needed in unconscious patients or those with equivocal findings, with pressures >30 mmHg or within 30 mmHg of diastolic pressure indicating compartment syndrome requiring immediate fasciotomy 1

The anterior compartment is most commonly affected in tibia fractures, but all four compartments of the lower leg should be assessed. Early recognition is critical as delayed treatment can lead to permanent muscle and nerve damage, contractures, or even limb loss. Additional risk factors for developing ACS after lower limb trauma include open fracture, intramedullary nailing, anticoagulation, high energy injury, penetrating trauma, vascular injury, burns, the use of tourniquets, and haemophilia, as noted in the regional analgesia for lower leg trauma and the risk of acute compartment syndrome guideline 1.

From the Research

Tibia Fractures Requiring Compartment Checks

• All patients with musculoskeletal trauma, irrespective of age, sex, fracture type, or injury mechanism, are at increased risk for acute compartment syndrome (ACS) 2
• Patients with tibia fractures who have increased milligram morphine equivalent (MME) requirements and higher pain scores are at a higher risk of developing ACS 3
• The rate of compartment syndrome is highest in diaphyseal tibia fractures (8.1%), followed by proximal (1.6%) and distal (1.4%) groups 4
• Young patients with diaphyseal fractures are at a higher risk of developing compartment syndrome, and warrant increased vigilance and suspicion for ACS 4

Factors Associated with Compartment Syndrome

• Increased MME requirements and pain scores within two hours of surgery are significant predictors of ACS following tibia fracture 3
• Decreasing age is an independent predictor for the development of compartment syndrome in diaphyseal tibial fractures 4
• The presence of associated fractures, concomitant head/chest/abdominal/pelvic injury, and open versus closed fracture (Gustilo-Anderson classification if open) may also be associated with the development of compartment syndrome in tibial fractures 4

Diagnosis and Treatment of Compartment Syndrome

• Current diagnosis of ACS is based on clinical findings and intramuscular pressure (IMP) measurement 5
• Measurement of IMP, ideally continuously, is the cornerstone of surgical decision-making for ACS 5
• Numerous investigators are searching for less invasive and more direct measurements of tissue ischemia, including measurement of oxygenation, biomarkers, and even neurologic monitoring 5