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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 51  |  Issue : 6  |  Page : 241-244

Open fracture of tibia mid-shaft associated with the contralateral leg acute compartment syndrome without fracture


Department of Orthopedic, Chi-Mei Medical Center, Tainan, Taiwan

Date of Submission26-Feb-2018
Date of Decision23-Apr-2018
Date of Acceptance19-Jul-2018
Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Chi-Rung Chung
Department of Orthopedic, Chi-Mei Medical Center, No. 901, Zhonghua Road, Yongkang District, Tainan City
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_22_18

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  Abstract 

The acute extremity compartment syndrome is caused by increased compartment volume or restriction of compartment size. There are 23% of all compartment syndrome is caused by isolated soft-tissue injury especially in crushing injury. We report a 30-year-old male with the initial diagnosis of the right tibia open fracture, Gustilo Type II, due to a motor-vehicle accident. Besides the right leg condition, he was continually suffered from left leg pain, where the X-ray revealed no apparent fracture since the collision. The physical examination showed no skin lesion and deformity; however, numbness and tightness were noted, toe stretching pain+, Pedis Dorsalis Artery+, Posterior Tibialis Artery+. Doppler showed the presence of PDA and PTA blood flow. Nine hours after the injury, pain and numbness of his left leg and foot still persisted and also pale and pulseless developed. Doppler for his left leg was done again and showed the negative result of PTA and PDA. Emergent bilateral side fasciotomy for his left leg was arranged, and the cardiovascular department was consulted for intraoperative angiography. The fasciotomy wound was cared with sterilized saline wet dressing for 3 days. Medial fasciotomy was closed with delayed primary method, and the lateral sides were treated with split-thickness skin graft. Acute compartment syndrome is diagnosed by the interpretation of a collection of clinical signs and symptoms. In a patient with a swollen limb, in the absence of a fracture and for whom, there is a suspicion of an acute compartment syndrome, methods, technology, and application for the early detection of acute compartment syndrome is important and also provides promising opportunities for the clinicians to perform early interventions.

Keywords: Absence of fracture, acute compartment syndrome, early detection, fasciotomy, trauma


How to cite this article:
Wu TM, Chung CR, Huang PC, Wu CD. Open fracture of tibia mid-shaft associated with the contralateral leg acute compartment syndrome without fracture. Formos J Surg 2018;51:241-4

How to cite this URL:
Wu TM, Chung CR, Huang PC, Wu CD. Open fracture of tibia mid-shaft associated with the contralateral leg acute compartment syndrome without fracture. Formos J Surg [serial online] 2018 [cited 2019 Mar 20];51:241-4. Available from: http://www.e-fjs.org/text.asp?2018/51/6/241/247309


  Introduction Top


The acute extremity compartment syndrome is considered a severe complication caused by increased compartment volume or restriction of compartment size. It is mostly caused by high-energy blunt trauma, which is usually associated with a fracture especially within a long bone.

Acute compartment syndrome in the absence of fracture has been reported in several cases including spontaneous cases and those caused by soft-tissue injury or even in a well leg. There are 23% of all compartment syndrome is caused by isolated soft-tissue injury especially in crushing injury.[1] We reported a case of acute compartment syndrome in the left leg, which is the relative sound side in a high-energy trauma.


  Case Report Top


This 30-year-old male without specific history was sent to our emergency department following a motor-vehicle traffic accident with the initial diagnosis of the right tibia and fibula midshaft open fracture, Gustilo Type II, with open wound about 1.2 cm [Figure 1]. Besides the right leg condition, he had been continually suffered from contralateral left leg cramping pain since the collision [Figure 2]. Physical examination showed no apparent skin lesion and deformity of the leg; however, numbness and palpable tightness compared with the right leg were noted, the toe-stretching pain was not obvious, and dorsalis pedis artery and posterior tibial artery were all palpable, and the left leg blood flow was all presence under Doppler scan. X-ray of left leg revealed neither apparent fracture pattern nor anomaly. About 9 h after the trauma, the left leg and foot pain and numbness still persisted, and also, pale and pulseless were found. Bedside Doppler for the left leg was followed again and showed the negative result of dorsalis pedis artery and posterior tibial artery. We arranged emergent left leg bilateral side fasciotomy; however, after the procedure, still neither significant improved in the distal perfusion nor pulsation noted by the Doppler scan; hence, we consulted the cardiovascular department for intraoperative angiography for the left leg, which revealed the presence of popliteal artery blood flow, but diminished anterior and posterior tibial artery [Figure 3]. After the emergent fasciotomy and angiography, we performed the scheduled open reduction with interlocking nail fixation of the right tibia and K-wire fixation of the right fibula. The open fasciotomy wound was cared with sterilized saline wet dressing for 3 days. Medial fasciotomy was closed with the delayed primary method, and a lateral fasciotomy was treated with split-thickness skin graft. No neurologic deficit with only mild residual pain at the time of discharge. The patient had been regularly followed up at our hospital for over a year; and from the latest follow-up, the right tibial and fibular fracture had healed properly, and there was no more residual discomfort noted at the left previous acute compartment syndrome leg [Figure 4].
Figure 1: Right tibia and fibula midshaft open fracture with open wound about 1.2 cm

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Figure 2: No sign of fracture was noted on the left leg

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Figure 3: Left: Emergent bilateral fasciotomy. Right: Intraoperative angiography revealed presence of left popliteal artery blood flow, but diminished anterior and posterior tibial artery

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Figure 4: Open reduction and internal fixations with intramedullary nail and K-wire were done on the right leg

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  Discussion Top


The only sign of our patient was the overrated pain, without any clue of acute compartment syndromes such as the presence of a fracture, significant passive stretching pain, sensory changes, or loss of motor power.

It was said that fractures account for approximately 75% of cases in acute compartment syndrome.[2] The rest of all compartment syndrome is caused by isolated soft-tissue injury especially in blunt crushing injury. Livingston et al.[3] had found that vascular causes were the most prevalent (28%), followed by trauma (26%), postoperative causes (21%), exertion (15%), and infection (10%). In a series of acute compartment syndrome with the absence of fracture,[4],[5],[6],[7],[8] it had shown that this kind of patient is more likely to have a delay to fasciotomy and also more likely to have muscle necrosis at fasciotomy than the acute compartment syndrome patients who have underlying fractures. In comparing the time from injury to fasciotomy for the groups with and without a fracture in acute compartment syndrome, the mean values were 26.3 versus 31.8 h, respectively. Moreover, to our acknowledgment, delay to the fasciotomy treatment is a single cause of a poor outcome in acute compartment syndrome;[9],[10],[11] hence, it is important for us to screen out and be alert of the potential acute compartment syndrome candidate.

The first sign of compartment syndrome is disproportionate pain to the severity of injury. Then, paresthesia and paralysis may gradually develop. The timing between these symptoms is variable; and even in sometimes, only a few signs will present. Hence, the diagnosis of the acute compartment syndrome is often difficult in patients who cannot give a clear history or participate in a rigorous clinical examination. In these patients, a reliable screening tool to diagnose a developing compartment syndrome would provide the opportunity to intervene earlier and avoid the sequelae of a delayed diagnosis. Compartment pressure measurement with needle manometer, wick catheter, or slit catheter had been described in several literatures.[12],[13],[14],[15] Experts have advocated fasciotomy for absolute compartment pressures from 30 to 45 mmHg.[16] A new ultrasonic intervention called pulsed phase-locked loop which was initially developed by Ueno et al.[17] can detect the very subtle movements of fascia that correspond to local arterial pulsation may be useful in the diagnosis of acute compartment syndrome.[18],[19] In a study by Abraham et al.,[20] laser Doppler flowmetry which works by analyzing the differences between the reflected and returned signals of light, shows the potential of detecting acute compartment syndrome. Creatine kinase, myoglobin, and fatty acid-binding protein are enzyme which elevated during myocardial muscles, and also skeletal muscles injury. However, the clinical meaning in acute compartment syndrome is still under debate. Magnetic resonance imaging can show the tissue changes in an established compartment syndrome in a very late stage but fails to identify early changes of an acute compartment syndrome. In 2008, Shadgan et al.[21] had reviewed several objective techniques such as near-infrared spectroscopy, muscle hardness measurement techniques, and tissue ultrafiltration; however, the efficiency and clinical values still need to be evaluated.

In our patient, we had provided repetitive physical examination because of severe cramping pain even after mild sedation and adequate pain control. Moreover, as soon as we noticed the diminishing of the pulse, we arranged the emergent fasciotomy and angiography. The pules were restored after the treatment. Neither significant neurological deficit nor residual pain at the latest follow up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
von Keudell AG, Weaver MJ, Appleton PT, Bae DS, Dyer GSM, Heng M, et al. Diagnosis and treatment of acute extremity compartment syndrome. Lancet 2015;386:1299-310.  Back to cited text no. 1
    
2.
Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003;85:625-32.  Back to cited text no. 2
    
3.
Livingston K, Glotzbecker M, Miller PE, Hresko MT, Hedequist D, Shore BJ, et al. Pediatric nonfracture acute compartment syndrome: A Review of 39 cases. J Pediatr Orthop 2016;36:685-90.  Back to cited text no. 3
    
4.
Chautems RC, Irmay F, Magnin M, Morel P, Hoffmeyer P. Spontaneous anterior and lateral tibial compartment syndrome in a type I diabetic patient: Case report. J Trauma 1997;43:140-1.  Back to cited text no. 4
    
5.
Kapoor V, Featherstone J, Jeffery IT. Acute anterior compartment syndrome of the forearm following lifting a heavy load. Injury 2000;31:212.  Back to cited text no. 5
    
6.
Kotak BP, Bendall SP. Recurrent acute compartment syndrome. Injury 2000;31:66-7.  Back to cited text no. 6
    
7.
Mathews PV, Perry JJ, Murray PC. Compartment syndrome of the well leg as a result of the hemilithotomy position: A report of two cases and review of literature. J Orthop Trauma 2001;15:580-3.  Back to cited text no. 7
    
8.
Shaw CJ, Spencer JD. Late management of compartment syndromes. Injury 1995;26:633-5.  Back to cited text no. 8
    
9.
McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br 1996;78:99-104.  Back to cited text no. 9
    
10.
Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint Surg Br 1984;66:93-7.  Back to cited text no. 10
    
11.
Rorabeck CH, Macnab I. The pathophysiology of the anterior tibial compartmental syndrome. Clin Orthop Relat Res 1975;(113):52-7.  Back to cited text no. 11
    
12.
Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res 1975;(113):43-51.  Back to cited text no. 12
    
13.
Rorabeck CH, Castle GS, Hardie R, Logan J. Compartmental pressure measurements: An experimental investigation using the slit catheter. J Trauma 1981;21:446-9.  Back to cited text no. 13
    
14.
Mubarak SJ, Hargens AR, Owen CA, Garetto LP, Akeson WH. The wick catheter technique for measurement of intramuscular pressure. A new research and clinical tool. J Bone Joint Surg Am 1976;58:1016-20.  Back to cited text no. 14
    
15.
Matsen FA 3rd, Winquist RA, Krugmire RB Jr. Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am 1980;62:286-91.  Back to cited text no. 15
    
16.
McQueen MM. Acute compartment syndrome. In: Buchholz RW, Heckman JD, Court-Brown CM, editors. Rockwood and Green's Fractures in Adults. Philadelphia, PA: Lippincott Williams and Wilkins; 2006. p. 425-43.  Back to cited text no. 16
    
17.
Ueno T, Ballard RE, Shuer LM, Cantrell JH, Yost WT, Hargens AR, et al. Noninvasive measurement of pulsatile intracranial pressure using ultrasound. Acta Neurochir Suppl 1998;71:66-9.  Back to cited text no. 17
    
18.
Lynch JE, Heyman JS, Hargens AR. Ultrasonic device for the noninvasive diagnosis of compartment syndrome. Physiol Meas 2004;25:N1-9.  Back to cited text no. 18
    
19.
Wiemann JM, Ueno T, Leek BT, Yost WT, Schwartz AK, Hargens AR, et al. Noninvasive measurements of intramuscular pressure using pulsed phase-locked loop ultrasound for detecting compartment syndromes: A preliminary report. J Orthop Trauma 2006;20:458-63.  Back to cited text no. 19
    
20.
Abraham P, Leftheriotis G, Saumet JL. Laser Doppler flowmetry in the diagnosis of chronic compartment syndrome. J Bone Joint Surg Br 1998; 80:365-9.  Back to cited text no. 20
    
21.
Shadgan B, Menon M, O'Brien PJ, Reid WD. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma 2008;22:581-7.  Back to cited text no. 21
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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