|Year : 2013 | Volume
| Issue : 3 | Page : 294-297
Compartment syndrome like picture in metaphyseal comminuted fracture of tibia treated by locking plate due to tight closure
Prafulla Herode, Dhammapal S Bhamare, Bhamare K Biswas, Bharati Deokar
Department of Orthopaedics, Padm. D.Y. Patil Medical College and Research Centre, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||5-Jul-2013|
Department of Orthopaedics, Padm. D.Y. Patil Medical College and Research Centre, Sant Tukaram Nagar, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
A 22-year-old male came to casualty on 5 th May 2012 after a fall from motorcycle. He complained of excruciating pain and swelling over right knee. There was an open wound of 7 × 2 cm over supra-patellar region and diffuse swelling over knee joint with severe tenderness over proximal aspect of right tibia. X-ray showed intra-articular fracture of proximal tibia extending to diaphysis classified as type 6 by Schatzker classification for proximal tibia, with fibula shaft transverse fracture. The skin over the fracture was contused. Debridement with primary wound closure was done in emergency. Skeletal traction was applied through a lower tibial Steinman pin. Patient was operated after 15 days when wound healed and swelling subsided. Locking plate was applied on medial aspect using Minimally invasive percutaneous plate osteosysthesis (MIPPO) technique. Post-operatively over 4 hours patient developed severe pain and swelling in operated leg which mimicked compartment syndrome. Suture removal was done immediately in the ward from the distal aspect, which relieved the symptoms but lead to exposure of the plate. A rotational flap was done to cover the plate in coordination with a plastic surgeon on the next day.
Keywords: Bohler-Braun frame, compartment syndrome, Minimally invasive percutaneous plate osteosysthesis, Schatzker classification of proximal tibia
|How to cite this article:|
Herode P, Bhamare DS, Biswas BK, Deokar B. Compartment syndrome like picture in metaphyseal comminuted fracture of tibia treated by locking plate due to tight closure. Med J DY Patil Univ 2013;6:294-7
|How to cite this URL:|
Herode P, Bhamare DS, Biswas BK, Deokar B. Compartment syndrome like picture in metaphyseal comminuted fracture of tibia treated by locking plate due to tight closure. Med J DY Patil Univ [serial online] 2013 [cited 2020 Sep 18];6:294-7. Available from: http://www.mjdrdypu.org/text.asp?2013/6/3/294/114655
| Introduction|| |
Fractures of the proximal tibia, particularly those that extend into the knee joint, are serious injuries that frequently result in functional impairment. In the past two decades, with improvements in surgical techniques and implants, there has been an unmistakable trend towards surgical management of these injuries. Nevertheless, proximal tibial fractures remain challenging because of their number, variety and complexity. The optimal method of management remains controversial. 
There is a significant risk of malunion in the treatment of proximal and distal tibial diametaphyseal fractures with all treatment methods including intramedullary nailing and non-operative management. Recently, the use of locking plate fixation utilizing minimally invasive technique has been put forward as one way of fixation, which can maintain alignment in proximal tibial fractures. 
| Case Report|| |
A 22-year male who had a fall from motorcycle experienced excruciating pain with swelling in right knee and unable to move his leg. There was an open horizontal wound of about 7 × 2 cm in supra-patellar region and diffuse swelling over right knee joint. On examination there was severe tenderness and crepitus over proximal aspect of right tibia. X-ray revealed intra-articular fracture of tibia extending to the diaphysis classified as type VI by Schatzker classification of proximal tibia. Patient was taken for surgery on emergency basis and thorough debridement was done with primary closure of the wound over suprapatellar region. Steinmann pin was inserted in lower metaphysis of tibia and skeletal traction was applied over a Bohler-Braun frame [Figure 1]. The patient was posted for definitive fixation, after swelling subsided and skin condition over the fracture improved. The surgery was done under spinal anesthesia and under tourniquet. A tourniquet was applied as it gives a bloodless field and decreases operative time. Patient was given supine position and knee flexed at 110' with the help of wooden frame. A stainless steel locking plate was applied over medial aspect of the tibia. We used a minimally invasive technique; proximal incision was taken over the antero-medial aspect of right knee and extended 5 cm from the joint line and distal incision taken about 4 cm over distal tibia antero-medially. 9 hole Proximal tibia locking plate made of stainless steel was placed along tibia extra-periosteally on the antero-medial surface and fixed proximally with three cancellous locking screws and distally with four cortical locking screw [Figure 2]. The total tourniquet time was one and half hour. Distal pulses were palpable after deflating the tourniquet. Postoperatively after 4 hours, the patient complained of severe pain in right leg. Swelling was noted. Stretch pain was found to be positive. The limb was cold, slightly bluish and distal pulsations were feeble. The symptoms mimicked compartment syndrome of the leg. Patient was posted for fasciotomy. However on removal of distal sutures in ward the patient got immediate relief of pain and within half an hour the leg was warm again and distal pulsations could be well felt. Formal fasciotomy was therefore not done. However this exposed distal part of the plate [Figure 3]. Hence next day a fasciocutaneous rotation flap was done to cover the plate in coordination with a plastic surgeon [Figure 4]. Dressing was done according to protocol and sutured removed on 12 th postoperative day [Figure 5]. No sign of infection was noticed during the entire period. The patient was discharged after teaching him knee range of movement and toe touch weight bearing using walker. A monthly follow-up of the patient was done. At three months the fracture was seen to be clinically united and the patient has full range of movement of knee [Figure 6]. The patient has no signs of any sequelae of compartment syndrome.
|Figure 1: Preoperative X-ray of right tibia-fibula with lower tibial pin traction|
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| Discussion|| |
Minimally invasive percutaneous plate osteosynthesis technique has recently been applied to fractures of the proximal and distal tibia and has been used in conjunction with newer designs of locking plates. Locking plate effectively creates a fixed angle type of construct between the screw and the plate. Locking the screw to the plate creates multiple fixed angle points of fixation whose mode of failure differs from conventional plating. Conventional plate-screw construct allows some toggle at the screw plate junction. Stability is provided by the compression of the plate to the bone, the fixation of the screws into bone, as well as compression at the fracture. The screws fail sequentially, allowing the plate to come off the bone. In contrast, locking plate provides a rigid construct and the locked screws must fail together with the screws pulling out of the bone at the same time which is rare. This type of construct has been known for a number of years to increase the pull-out strength of the screws. This increase in pullout strength is desirable in weakened bone such as may be encountered with osteopenia or osteoporosis. Also, the fixed angle of the screws into the metaphyseal portion of the bone provides bi-columnar support, transferring load from both sides of the proximal or distal tibia to the shaft. Hence plating is advocated as the treatment of choice for metaphyseo-diaphyseal fractures. 
Tibial fractures - both open and closed - are among the commonest causes of compartment syndrome in the leg. Compartment syndrome is an elevation of the interstitial pressure in a closed osseofascial compartment that results in microvascular compromise. Compartments with relatively noncompliant fascial or osseous structures most commonly are involved, especially the anterior and deep posterior compartments of the leg and the volar compartment of the forearm. Compartment syndrome can develop anywhere where skeletal muscle is surrounded by substantial fascia, such as in the buttock, thigh, shoulder, hand, foot, arm and lumbar paraspinous muscles. 
The diagnosis is usually suspected on clinical grounds. Warning symptoms are increase in pain, feeling of tightness or bursting in the leg or numbness in the leg.  Pain out of proportion with passive stretch of an involved muscle group is one of the earliest and most sensitive clinical sign. The so-called classical clinical findings such as changes on vascular examination or paralysis occur late and are less helpful in preventing morbidity. In leg anterior compartment is predominantly involved. 
Compartment syndrome after plating of metaphysis of tibia is rare especially with fracture of the fibula and use of a single plate applied on the medial aspect. Dual plating is known to give rise to problems of wound closure, wound dehiscence and infection. However compartment syndrome like picture due to tight closure after minimally invasive locking plating on medial aspect of tibia has not been reported. Here we would like to comment on the implant: locking plates are of thicker diameter as compared to conventional plates made of stainless steel due to the geometry of the plate design. Taking in account the smaller girth of our population, these thicker plates can give closure problems, and compartment syndrome like picture, and problems with wound healing.
We encountered certain limitations in this case like non-availability of low profile plates, which are required for medial side tibial plating. Lateral plating could have avoided skin closure problems but was not done as the skin over the lateral side was contused. Incisions through such skin would have caused problems with healing, wound dehiscence and infection. A tourniquet could have been avoided altogether decreasing the chances of a reperfusion injury. We did not look for a reperfusion injury in this case; lactic acid levels and CPK levels should have been done. Compartment pressure was not measured in this case. This is not a case of full blown compartment syndrome. The symptoms were due to tight closure giving rise to a compartment syndrome like picture. Sutured removal was done in the ward itself which relieved stretch pain of the patient, so it is difficult to say whether a particular group of muscles were involved or not. Fasciotomy was not done so no decompression of the muscles was done as is routinely done in compartment syndrome. So this has been described as a case of compartment syndrome like picture or a pseudo-compartment syndrome.
Such cases could also be treated using other method like external fixator or Ilizarov to avoid problems related to skin conditions.
| Conclusion|| |
Compartment syndrome like picture due to tight closure after open reduction and internal fixation of tibial fractures is rare. A caution with the use of thicker implants is advised. Monitoring postoperatively and early diagnosis can prevent the complications of compartment syndrome like picture. A tourniquet should also be avoided in minimally invasive techniques as there is very less blood loss, avoiding altogether problems with the use of a tourniquet.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]