Which orthopedic fractures are at risk for developing compartment syndrome?

Orthopedic Fractures at Risk for Compartment Syndrome

Tibial shaft fractures are at highest risk for developing compartment syndrome, with approximately 4-5% of all tibial fractures resulting in acute compartment syndrome (ACS). 1

High-Risk Fractures

• Tibial shaft (diaphyseal) fractures have the highest incidence of compartment syndrome (8.1%), significantly higher than proximal (1.6%) or distal (1.4%) tibial fractures 2
• Tibial plateau fractures, particularly Schatzker VI type fractures, carry a 5.72 times higher risk of developing compartment syndrome 3
• Proximal tibial fractures are at higher risk than middle or distal third fractures 4
• Proximal fibular fractures are at higher risk than middle or distal third fibular fractures 4
• Combined plateau-shaft injuries increase compartment syndrome risk by nearly 3 times 3
• Open tibial fractures with displaced, comminuted fibula fractures should raise suspicion for developing compartment syndrome 5

Risk Factors That Increase Compartment Syndrome Likelihood

• Young age, particularly men under 35 years with tibial fractures 1, 2
• High-energy mechanisms of injury increase risk by 3.1 times 3
• Presence of fibular fracture increases risk by 8.14 times 3
• Longer fracture length increases risk by 9.7 times 3
• Open fractures, particularly grade III open injuries 6
• Additional risk factors include:
  • Intramedullary nailing 1
  • Anticoagulation 1
  • Penetrating trauma 1
  • Vascular injury 1
  • Burns 1
  • Use of tourniquets 1
  • Haemophilia 1

Clinical Presentation and Diagnosis

• Pain out of proportion to the injury is the earliest and most reliable warning sign 7
• Pain on passive stretch of the affected muscle compartment is considered the most sensitive early sign 7
• Increasing firmness/tension of the compartment occurs as pressure rises 7
• Paresthesia (sensory changes) results from nerve ischemia 7
• Late signs include paralysis, pulselessness, pallor, and decreased temperature - indicating severe tissue damage 7

Diagnostic Challenges

• Clinical signs alone have low sensitivity but high specificity for diagnosing ACS 7
• Severe pain gives only approximately 25% chance of correctly diagnosing ACS 7
• The presence of both severe pain and pain on passive stretch increases positive predictive value to 68% 7
• When pain, pain on passive stretch, and paralysis are all present, positive predictive value reaches 93%, but paralysis indicates irreversible muscle ischemia may have already occurred 7

Pediatric Considerations

• Normal leg compartment pressures in children are higher than in adults (13-16 mmHg vs. 0-10 mmHg) 1
• Children aged 12-19 years have a high prevalence of ACS after tibial fracture 1
• Children may have difficulty articulating symptoms such as pain and paraesthesia 1
• Consider using the "three As" to diagnose ACS in children: anxiety, agitation, and analgesic requirement 1

Management Approach

• Maintain a high index of suspicion in at-risk patients 7
• Position the limb at heart level (not elevated) when ACS is suspected 7
• Measure compartment pressures if diagnosis remains in doubt, particularly in obtunded patients 7
• Arrange urgent surgical consultation for fasciotomy when ACS is diagnosed 7

Important Pitfalls to Avoid

• Waiting for late signs of ACS can lead to significant tissue damage 7
• Relying solely on palpation for diagnosis is unreliable 7
• Delaying diagnosis in obtunded patients can lead to poor outcomes 7
• Missing ACS in patients without fractures (can occur with soft tissue injuries alone) 7
• Elevating the limb excessively can further decrease perfusion pressure and worsen ACS 7

Cumulative Risk Assessment

• The presence of multiple risk factors has a cumulative effect on ACS risk 3
• Patients with 3 and 4 predictive markers demonstrated a 20% and 27% chance of developing ACS respectively 3
• This information should be used to identify high-risk patients requiring vigilant monitoring 3