Anterior tibial compartment syndrome JAMES P. WADDELL, MD, FRCS[C]
The anterior tibial compartment syndrome is a poorly understood complication of injury to the lower limb. Two illustrative cases are reported to serve as a basis for discussion of diagnosis and management.
Case reports Case I A 21-year-old man injured his right leg while skiing; the sole injury was a transverse fracture of the midshaft of the tibia and of the fibula. Three hours later a closed reduction of the fracture was carried out under general anesthesia. The reduction was excellent and the fracture was immobilized in a long-leg cast. At 12 hours he began to complain of increasing pain in his right foot; the nurses' notes at this time indicated that the colour of the toes was good and the movement fair. He continued to complain of pain. At 18 hours a physician noted good colour and warmth of the toes but, because of pain, split the cast throughout its length. Pain continued undiminished and, at 30 hours, paralysis was noted by the nurses; the patient compained of numbness of the foot and of severe pain in the leg and foot. Peripheral pulses at this time were noted to be excellent. Case 2 A 43-year-old man, injured in a motor vehicle accident, sustained as the only injury a compound fracture of the supracondylar area of the left femur. Physical examination soon thereafter confirmed the nature of the injury and revealed absence of ankle pulsation. A femoral arteriogram demonstrated a block in the popliteal artery. Open reduction and internal fixation of his fractured femur was carried out 4.5 hours after injury. The artery was repaired by resecting the intimal tear and thrombus from the artery, and carrying out a primary anastomosis. The total ischemic time was approximately 6 hours, and an excellent pulse was restored at the ankle. Sixteen hours after operation the patient complained of pain in his left leg and foot; inspection revealed good colour of the toes, fair movement of the foot and ankle, and excellent pulses. At 24 hours he complained of numbness, extreme pain and weakness of the foot and ankle. Physical examination at that time revealed excellent pulses and good warmth but total paralysis of toe and ankle extensors.
drome was originally described by Horn1 as a phenomenon occurring after exercise in army recruits; he reported that the muscles of the anterior compartment of the leg became swollen, tense and eventually necrotic, in the absence of direct injury. The term has gradually come to be applied to a variety of disorders capable of producing the same end result - namely, necrosis of muscle in the anterior tibial compartment. Rorabeck, Macnab and Waddell2 divided these various injuries into four groups; including Horn's idiopathic group these are post-traumatic, postembolic, and that developing after relief of temporary vascular occlusion. The underlying pathogenesis of all varieties of the syndrome is the same. It can be understood by reference to the pertinent anatomy (Fig. 1). The anterior compartment is bounded by unyielding walls of fascia and bone and, if the pressure within the compartment increases sufficiently to interfere with arteriolar and capillary flow, the muscle becomes necrotic. Such pressure might result from the formation of a hematoma following a fracture (as occurred in case 1) or the postischemic edema and swelling that develops secondary to prolonged ischemia (as in case 2). Since the increase in pressure required to close muscle arterioles effectively is only 30 mm Hg2 the arterial pulse distal to the compartment and the anterior tibial artery and dorsalis pedis artery is not occluded. Diagnosis This condition is relatively easy to diagnose if the physician is aware of the existence of such a complication. Pain is the first symptom; it is more severe than one would expect for the basic underlying condition. The pain is frequently referred to the distal shin and ankle, and not over the area directly involved by injury. The second symptom is exacerbation of pain with
JIhlalls anterior Estesmer halinsle league Extensor e.g.. dlglterum
Comment Pathogenesis Anterior
passive flexion of the toes. This is followed by numbness between the first and second toes, secondary to pressure on the nerves within the compartment. Finally, the toe and ankle extensors become paralysed. The anterior tibial compartment is another form of Volkmann's ischemia, though it is rather more localized and certainly less well known than the more famous variety that affects the forearm. However, it is distinct from Volkmann's ischemia in that the distal arterial pulse is not totally obliterated and the diagnosis will be overlooked unless the less obvious signs of ischemia are sought. Treatment Once the diagnosis has been made there is only one effective form of treatment: adequate decompression of the compartment throughout its length. Although some surgeons advocate subcutaneous fasciotomy, I prefer open fasciotomy throughout the length of the compartment, since this is the only way in which adequacy of decompression can be confirmed. Unless the condition is advanced, and evidence of muscle necrosis certain at the time of fasciotomy, no debridement is carried out simultaneously with the initial fasciotomy. A second surgical procedure, planned in 3 to 5 days, with debridement of necrotic muscle and then secondary closure over skin graft if this is possible, is preferred. In the patient referred to in case 1, two separate muscle debridements were required, and eventual wound healing was secured by split-thickness skin graft. In the other patient secondary closure was done at 5 days, as the fasciotomy had been performed sufficiently early to prevent muscle necrosis. Conclusion The importance of the anterior tibial compartment syndrome is fourfold: 1. It is more common than previously accepted. 2. Heightened awareness will increase the ease of diagnosis. 3. Early diagnosis and simple fasciotomy will greatly diminish morbidity. 4. Failure to diagnose and treat properly results in needless paralysis and deformity of the limb. References
tibial
compartment
syn-
Reprint requests to: Dr. J.P. Waddell, Department of surgery, orthopedic service, St. Michael's Hospital, 30 Bond St., Toronto, Ont. M5B 1W8
FIG. 1-Cross-section of leg. Note rigid walls of anterior compartment.
1. HORN CE: Acute ischemia of the anterior tibial muscles and long extensor muscles of the toes. J Bone Joint Surg 27: 615, 1945 2. RORABECK CH, MACNAB I, WADDELL JP: Anterior tibial compartment syndrome: a clinical and experimental review. Can J Surg 15: 249, 1972
CMA JOURNAL/MARCH 19, 1977/VOL. 116 653
The anterior tibial compartment syndrome is a poorly understood complication of injury to the lower limb. Two illustrative cases are reported to serve as a basis for discussion of diagnosis and management.
Case reports Case I A 21-year-old man injured his right leg while skiing; the sole injury was a transverse fracture of the midshaft of the tibia and of the fibula. Three hours later a closed reduction of the fracture was carried out under general anesthesia. The reduction was excellent and the fracture was immobilized in a long-leg cast. At 12 hours he began to complain of increasing pain in his right foot; the nurses' notes at this time indicated that the colour of the toes was good and the movement fair. He continued to complain of pain. At 18 hours a physician noted good colour and warmth of the toes but, because of pain, split the cast throughout its length. Pain continued undiminished and, at 30 hours, paralysis was noted by the nurses; the patient compained of numbness of the foot and of severe pain in the leg and foot. Peripheral pulses at this time were noted to be excellent. Case 2 A 43-year-old man, injured in a motor vehicle accident, sustained as the only injury a compound fracture of the supracondylar area of the left femur. Physical examination soon thereafter confirmed the nature of the injury and revealed absence of ankle pulsation. A femoral arteriogram demonstrated a block in the popliteal artery. Open reduction and internal fixation of his fractured femur was carried out 4.5 hours after injury. The artery was repaired by resecting the intimal tear and thrombus from the artery, and carrying out a primary anastomosis. The total ischemic time was approximately 6 hours, and an excellent pulse was restored at the ankle. Sixteen hours after operation the patient complained of pain in his left leg and foot; inspection revealed good colour of the toes, fair movement of the foot and ankle, and excellent pulses. At 24 hours he complained of numbness, extreme pain and weakness of the foot and ankle. Physical examination at that time revealed excellent pulses and good warmth but total paralysis of toe and ankle extensors.
drome was originally described by Horn1 as a phenomenon occurring after exercise in army recruits; he reported that the muscles of the anterior compartment of the leg became swollen, tense and eventually necrotic, in the absence of direct injury. The term has gradually come to be applied to a variety of disorders capable of producing the same end result - namely, necrosis of muscle in the anterior tibial compartment. Rorabeck, Macnab and Waddell2 divided these various injuries into four groups; including Horn's idiopathic group these are post-traumatic, postembolic, and that developing after relief of temporary vascular occlusion. The underlying pathogenesis of all varieties of the syndrome is the same. It can be understood by reference to the pertinent anatomy (Fig. 1). The anterior compartment is bounded by unyielding walls of fascia and bone and, if the pressure within the compartment increases sufficiently to interfere with arteriolar and capillary flow, the muscle becomes necrotic. Such pressure might result from the formation of a hematoma following a fracture (as occurred in case 1) or the postischemic edema and swelling that develops secondary to prolonged ischemia (as in case 2). Since the increase in pressure required to close muscle arterioles effectively is only 30 mm Hg2 the arterial pulse distal to the compartment and the anterior tibial artery and dorsalis pedis artery is not occluded. Diagnosis This condition is relatively easy to diagnose if the physician is aware of the existence of such a complication. Pain is the first symptom; it is more severe than one would expect for the basic underlying condition. The pain is frequently referred to the distal shin and ankle, and not over the area directly involved by injury. The second symptom is exacerbation of pain with
JIhlalls anterior Estesmer halinsle league Extensor e.g.. dlglterum
Comment Pathogenesis Anterior
passive flexion of the toes. This is followed by numbness between the first and second toes, secondary to pressure on the nerves within the compartment. Finally, the toe and ankle extensors become paralysed. The anterior tibial compartment is another form of Volkmann's ischemia, though it is rather more localized and certainly less well known than the more famous variety that affects the forearm. However, it is distinct from Volkmann's ischemia in that the distal arterial pulse is not totally obliterated and the diagnosis will be overlooked unless the less obvious signs of ischemia are sought. Treatment Once the diagnosis has been made there is only one effective form of treatment: adequate decompression of the compartment throughout its length. Although some surgeons advocate subcutaneous fasciotomy, I prefer open fasciotomy throughout the length of the compartment, since this is the only way in which adequacy of decompression can be confirmed. Unless the condition is advanced, and evidence of muscle necrosis certain at the time of fasciotomy, no debridement is carried out simultaneously with the initial fasciotomy. A second surgical procedure, planned in 3 to 5 days, with debridement of necrotic muscle and then secondary closure over skin graft if this is possible, is preferred. In the patient referred to in case 1, two separate muscle debridements were required, and eventual wound healing was secured by split-thickness skin graft. In the other patient secondary closure was done at 5 days, as the fasciotomy had been performed sufficiently early to prevent muscle necrosis. Conclusion The importance of the anterior tibial compartment syndrome is fourfold: 1. It is more common than previously accepted. 2. Heightened awareness will increase the ease of diagnosis. 3. Early diagnosis and simple fasciotomy will greatly diminish morbidity. 4. Failure to diagnose and treat properly results in needless paralysis and deformity of the limb. References
tibial
compartment
syn-
Reprint requests to: Dr. J.P. Waddell, Department of surgery, orthopedic service, St. Michael's Hospital, 30 Bond St., Toronto, Ont. M5B 1W8
FIG. 1-Cross-section of leg. Note rigid walls of anterior compartment.
1. HORN CE: Acute ischemia of the anterior tibial muscles and long extensor muscles of the toes. J Bone Joint Surg 27: 615, 1945 2. RORABECK CH, MACNAB I, WADDELL JP: Anterior tibial compartment syndrome: a clinical and experimental review. Can J Surg 15: 249, 1972
CMA JOURNAL/MARCH 19, 1977/VOL. 116 653
