Acute Compartment Syndrome in the Treatment of Tibial Fractures: Clinical and Radiological Risk Factors

Introduction: This Privat Docent thesis collects the author's recent retrospective study results on potential clinical and radiological risk factors for the occurrence of acute compartment syndrome in the treatment of tibia fractures. Clinical evaluation of acute compartment syndrome and intra-compartmental pressure measurements are not completely reliable. This might lead to difficulties in diagnosing or ruling out acute compartment syndrome, especially in patients with equivocal clinical signs and those with loco-regional anesthesia, intubated, sedated or obtunded. Alternative predictors of acute compartment syndrome need to be determined. The objective of the author’s research was therefore to analyze the relation between key demographic, injury-related, clinical and radiographic factors in patients with proximal tibia, diaphyseal tibia and distal tibia fractures and the subsequent development of acute compartment syndrome. Recent publications and current research: -Association between open tibia fractures and acute compartment syndrome (retrospective cohort study, 711 consecutive adult patients with 725 tibia fractures): this study highlighted an association between open Gustilo type 2 and 3 lesions and occurrence of acute compartment syndrome in proximal intra-articular fractures only; there was no association with closed or any type of open fractures in extra-articular fractures, and there were not enough acute compartment syndrome cases among distal intra-articular fractures to draw conclusions. -Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial plateau fractures (retrospective cohort study, 265 consecutive adult patients with 269 intra-articular tibial plateau fractures): two parameters related to the occurrence of acute compartment syndrome in tibial plateau fractures were pointed out, namely the presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification. -Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures (retrospective cohort study, 270 consecutive adult patients with 273 tibial shaft fractures): one radiological parameter related to the occurrence of acute compartment syndrome was pointed out: this parameter was a longer distance between the center of the fracture and the talar dome, in other words a fracture located more proximally within the tibia. Diaphyseal tibial fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries were also at higher risk of acute compartment syndrome. Radiographic signs of higher fracture displacement were not associated with ACS occurrence. -Current research – Association between muscle mass surrounding the fracture site and occurrence of acute compartment syndrome in extra-articular fractures of the tibia: this research is aimed at refining the conclusion of the previous study, in which the most powerful acute compartment syndrome predictor in tibial shaft fractures was the distance between the talar dome and the center of the tibial shaft fracture, meaning that a more proximal fracture was more prone to be associated with the development of acute compartment syndrome. The explanation for this finding was that a fracture surrounded by a larger muscle mass (proximal diaphysis) may result in a higher amount of energy transferred to the soft tissues and potentially to acute compartment syndrome development. This ongoing research consists of analyzing acute compartment syndrome rate and muscle mass associated to each eight arbitrarily pre-defined isometric tibia segments in order to evaluate a potential correlation between both these factors. Conclusions and perspective for future research: Early recognition of injuries at risk of acute compartment syndrome is essential in the screening and treatment of tibia fractures, especially by intubated, sedated or obtunded patients. Author’s recent publications were able to demonstrate different risk factors for the occurrence of acute compartment syndrome during the treatment of tibia fractures. When one or more risk factor is present, regular clinical examinations and/or repeated or continuous intra-compartmental pressure measurements should be performed before and after the surgery to monitor soft tissue condition, even if the initial assessments were unremarkable regarding the eventual presence of acute compartment syndrome. All the factors highlighted by the author in predicting the occurrence of acute compartment syndrome would need to be confirmed and refined by larger studies

The intraseptal course of the superficial peroneal nerve: an anatomic study

Anatomic and clinical studies show many variants of the superficial peroneal nerve (SPN) course and branching within the compartments and at the suprafascial layer. The anatomy of the transition zone from the compartment to the subcutaneous layer has been occasionally described in the literature, mainly in studies reporting the intraseptal SPN variant in 6.6% to 13.6% of patients affected by the SPN entrapment syndrome.Despite the little evidence available, the knowledge of the transition zone is relevant to avoid iatrogenic lesions to the SPN during fasciotomy, open approaches to the leg and ankle, and SPN decompression.Our anatomic study aimed to describe the SPN transition site and to evaluate the occurrence of a peroneal tunnel and of an intraseptal SPN variant

Médecine de catastrophe: mission Haïti

On January 12th, 2010, an earthquake of a magnitude of 7 on the Richter scale striked the southwest of Haiti, including the capital Port-au-Prince, and provoked immense human and material damages. Estimated number of victims is 300000 wounded, 230000 dead and 1000000 homeless. This disaster generated at once an immense and urgent need for sanitary resources. In this context, an emergency medical humanitarian mission was engaged by the Swiss Confederation (humanitarian aid depending on the Development and Cooperation Direction); this article describes this emergency mission, its progress, the committed staff and means, and the type of treated patients

Anterior shoulder instability: histomorphometric study of the subscapularis and deltoid muscles

Recurrent traumatic anterior shoulder dislocation results in soft tissues lesions around the glenohumeral joint. The subscapularis muscle is a major active stabilizer of the shoulder and the hypothesis of the current study is that one would expect pathologic changes within its substance secondary to the trauma. A histomorphometric study of the subscapularis muscle was done of 52 patients operated on for recurrent traumatic anterior shoulder dislocation. At the time of surgery biopsy specimens were taken of the subscapularis muscle and the ipsilateral deltoid muscle as a comparison and to see if any changes were present. The results revealed interstitial fibrosis within the subscapularis muscle compatible with muscle scarring, and modifications in the ratio of fiber types as usually is seen with disuse atrophy. Both of these findings may alter strength and stability and therefore the function of the glenohumeral joint. The histologic findings were not compatible with a denervation pattern. After traumatic anterior shoulder dislocation rehabilitation of the subscapularis muscle is recommended

Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures?

We reviewed 155 consecutive patients who were treated with a proximal femoral nail from 1997 to 2001 to determine the rate of implant specific complications. Results were stratified according to fracture type and surgeon experience to determine which problems occurred in these groups. One year postoperative followup was available for 129 of 132 surviving patients (98%). Failure of fixation occurred in three patients (2%), and a femoral shaft fracture occurred in one patient (0.7%). Fixation failures included one cutout, one delayed fracture healing, and one lateral displacement of the antirotation screw. The total reoperation rate was high (12%) mainly because of hardware removals, which occurred in 13 patients (8.6%). Stratification of results showed that hematomas and iliotibial tract irritation occurred more commonly with lesser surgical experience. General complications and intraoperative problems were seen more often with subtrochanteric fractures. Because the high reoperation rate with the proximal femoral nail is a concern, extramedullary devices continue to be the preferred implants for treatment of stable trochanteric fractures. The low rates of femoral shaft fractures and failure of fixation suggest the proximal femoral nail is useful for treatment of unstable trochanteric and subtrochanteric fractures

Osteosynthesis of non-displaced femoral neck fractures in the elderly population using the femoral neck system (FNS): short-term clinical and radiological outcomes

Femoral neck fractures (FNF) are frequent in the elderly population, and surgical management is indicated in the vast majority of cases. Osteosynthesis is an alternative to arthroplasty for non-displaced FNF. Triple screw construct (TS) and the dynamic hip screw system (DHS) are considered gold standards for osteosynthesis. The newly available femoral neck system (FNS) currently lacks evidence as to whether it is a valid alternative to TS and DHS. The purpose of this study was to evaluate the short-term clinical and radiological outcomes after non-displaced (Garden I and II) FNF osteosynthesis using TS, DHS, and FNS

A case report depicting patient's installation on the fracture table when an ankle spanning external fixator is already in place

Fractures of the proximal and diaphyseal femur are frequently internally fixed using a fracture table. Moreover, some femoral neck fractures may be treated with total hip arthroplasty using a direct anterior approach and a traction table. Fracture and traction tables both use a boot tightly fitted to the patient's foot in order to: 1) obtain fracture reduction by traction and adequate rotation exerted on the slightly abducted or adducted extremity; or 2) adequately expose the hip joint using traction, rotation and extension to implant total hip arthroplasty components. In some instances, multiply injured patients may present with both a proximal or diaphyseal femur fracture and a diaphyseal or distal tibia or ankle fracture necessitating an ankle spanning external fixator on the same limb. Frequently, the tibia or ankle fracture has to be treated first, and standard use of the fracture or traction table may be thereafter difficult due to the external fixator construct preventing tight fitting of the boot to the patient's foot

Epidemiology of high-energy blunt pelvic ring injuries: a three-year retrospective case series in a level-I trauma center

Background: High-energy pelvic ring injuries (PRI) represent a heavy burden for institutions treating severely injured patients. Epidemiological data knowledge may help to provide them appropriate management. Only two epidemiologic studies about high-energy PRI were published during last decade. This study aimed to determine the gender-specific and global incidences of high-energy blunt AO/OTA type B or C PRI and their frequency among high-energy blunt trauma. It further reports the spectrum of these injuries and compares their characteristics and outcomes to high-energy blunt trauma without type B or C PRI. Hypothesis: Type B or C PRI incidence isn't gender specific and approximates 5/100,000/year. Patients and methods: A prospective database of a level-I trauma center serving approximately 500,000 inhabitants was retrospectively queried for all high-energy trauma patients injured between 01.01.2014 and 12.31.2016. Inclusion criteria were: alive emergency department delivery; entire acute treatment at the authors' institution; age &gt;16. Exclusion criteria were: penetrating, blast, burn and electrical injuries; drownings; low-energy trauma; patients living outside the institution's catchment area. Three authors performed PRI classifications. Clinical data were extracted from the database. Results: We analyzed 434 patients. High-energy blunt type B or C PRI incidence was 3.8/100,000/year without gender disparity (p=0.6697). High-energy blunt trauma incidence was lower in women than in men (20.5 vs. 51.6/100,000/year, p&lt;0.001). Type B or C PRI frequency during high-energy blunt trauma was higher in women than in men (17.6% vs. 7.9%, p=0.003). Type B or C PRI patients were more severely injured and needed more treatment resources than other high-energy blunt trauma patients but didn't present higher complication or death rates. Discussion: The incidence of high-energy blunt type B or C PRI was comparable to previously published data. Women were less likely to sustain a high-energy blunt trauma, but when they sustained one, they were more likely to have a type B or C PRI. Despite higher injury severity score and resource requirements, complication and death rates weren't different between type B or C PRI patients and other high-energy blunt trauma patients. Level of evidence: Level III, retrospective cohort study.</p