Rev. bras. ortop. vol.49 número1

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rev bras ortop.2014;49(1):86–88

w w w . r b o . o r g . b r

Case

report

Compartment

syndrome

after

tibial

plateau

fracture

夽

Guilherme

Benjamin

Brandão

Pitta

∗

_,

_Thays

_Fernanda

_Avelino

_dos

_Santos,

Fernanda

Thaysa

Avelino

dos

Santos,

Edelson

Moreira

da

Costa

Filho

UniversidadeEstadualdeCiênciasdaSaúdedeAlagoas,Maceió,AL,Brazil

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Articlehistory:

Received6February2013

Accepted9April2013

Keywords:

Tibialfractures

Bonewires

Fracturefixationinternal

a

b

s

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r

a

c

t

Fracturesofthetibialplateauarerelativelyrare,representingaround1.2%ofallfractures.

Thetibia,duetoitssubcutaneouslocationandpoormusclecoverage,isexposedandsuffers

largenumbersoftraumas,notonlyfractures,but alsocrushinjuriesandsevere

bruis-ing,amongothers,whichatanygivenmoment,couldleadcompartmentsyndromeinthe

patient.Thecaseisreportedofa58-year-oldpatientwho,followingatibialplateau

frac-ture,presentedcompartmentsyndromeofthelegandwassubmittedtodecompressive

fasciotomyofthefourrightcompartments.Afterosteosynthesiswithinternalfixationof

thetibialplateauusinganL-plate,thepatientagaindevelopedcompartmentsyndrome.

Ltda.Allrightsreserved.

Síndrome

compartimental

pós-fratura

de

platô

tibial

Palavras-chave:

Fraturasdatíbia

Fiosortopédicos

Fixac¸ãointernadefraturas

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e

s

u

m

o

Asfraturasdeplatôtibialsãorelativamenteraraserepresentam,aproximadamente,1,2%

detodasasfraturas.Atíbia,porsualocalizac¸ãosubcutâneaepobrecoberturamuscular,está

expostaasofrergrandesquantidadesdetraumatismos,quenãosãosomentefraturas,mas

tambémlesõesporachatamento,contusõesseveras,entreoutrasque,emumdeterminado

momento,podemcausarnoenfermoasíndromecompartimental.Érelatadoocasodeum

pacientede58anosque,apósfraturadeplatôtibial,apresentousíndromecompartimental

depernaefoisubmetidoàfasciotomiadescompressivadosquatrocompartimentosdireitos.

Apósosteossíntesecomfixac¸ãointernadeplatôtibialcomplacaemL,evoluiucomnova

síndromecompartimental.

Ltda.Todososdireitosreservados.

夽

Pleasecitethisarticleas:PittaGBB,dosSantosTFA,dosSantosFTA,daCostaFilhoEM.Síndromecompartimentalpós-fraturadeplatô

tibial.RevBrasOrtop.2014;49:86–88.

∗ _{Corresponding}_author_.

E-mail:guilherme@guilhermepitta.com(G.B.B.Pitta).

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rev bras ortop.2014;49(1):86–88

87 Introduction

Tibialplateaufracturesarerelativelyrareandrepresent1.2%

ofall fractures.1 _The _tibia _is _exposed _to _a _lot _of_traumas,

thatcancausecompartmentsyndrome(CS).2_With_a

diagno-sisofSC,fasciotomyisindicatedfortheopeningofthefour

compartments.3

Theaimofthisstudyistoreportacaseofcompartment

syndromeaftertibialplateaufracturetreatedwithfasciotomy

priortoosteosynthesisoftibialmetaphysisandwhich

devel-opedintoacompartmentsyndromepostoperatively.

Case

report

Patient,male,58yearsold,fellfromheight,developedpain

inthe rightlower limb(RLL), associatedwithswelling and

difficultwalking.TheradiographofRLLrevealedfractureof

proximal tibial metaphysis and proximal fibular epiphysis

withinvolvementofthekneejoint.

Computed tomography of joints revealed comminuted

fractures ofthetibial plateauand fibular head.In the

bio-chemicaltests, it was foundthat totalCK=637U/L. Asthe

patientdevelopedprogressiveand severepain,paresthesia,

paresis,pallorandtenseandshinyskin,hewasreferredto

thevascularsurgeryservice,whereaDopplervascular

ultra-sonographywasrequested,excludingvenousthrombosis.The

indicationfordecompressive fasciotomywas basedon the

legnerveparesthesia,associatedwiththelimbvolume,when

comparedtothecontralaterallimb.

Thepatient was referred for decompressive fasciotomy

ofurgency in other surgical service. The surgery was

per-formedunder peridural anesthesia and medial and lateral

fasciotomieswere made,torelease thefour compartments

oftheleg.Finally,thesurgeonproceededwithhaemostasis,

partialsynthesisoffasciotomyandsurgicalwounddressing.

In that service, 48h later, the osteosynthesis was

per-formedunderspinalanesthesia.Fracturereduction,internal

fixationofthetibialplateaufractureinthemedialandlateral

sideswithL-plateandclosureoffasciotomywereperformed.

Duringthefracturemanipulationforitsfixationwiththe

L-plate,therightlegdevelopedprogressiveswellingandpain

inalocalizedcompartment,andthiscomplicationhasmade

thepatientseekourservice,whenweidentifiedtheneedto

reopentheincision(anewdecompressivefasciotomy),being

possibletovisualizethe platestem (Fig.1),which had not

beenpreviouslyremoved.Awounddressingwasmadeand,

after15dayspostoperatively,afreeskingraftinthelateral

regionoftheaffectedlegwasapplied,withexpositionofthe

plateandoftheinternalfixatorscrew(Fig.2).Aftersixweeks,

thelateralstemwasretired;then,totalclosureofthewound

wasmade,withagoodprogresssofarandwithoutassociated

comorbidities.

Discussion

Tibial plateau fractures account for 1% of all fractures; in

elderlysubjectstheyrepresentabout 8%oftheirfractures.4

These lesions are a challenge for surgeons, both for the

Fig.1–Reopeningofsurgicalincision(newdecompressive fasciotomy).

complexityofthebonelesion,asfortheassociatedsofttissue

injury.5

Important factors forthe diagnosis of this lesion are a

detailedclinicalhistoryandtheuseofimagingstudies.6_In_this

casereport,thepatientfirstsoughtanothersurgicalservice

withpainassociatedwithswellinganddifficultwalking;a

tib-ialplateaufracturewasdiagnosedwiththeaidofradiography

andcomputedtomography.

In several studies of fractures associated with

vascu-lar trauma, the likelihood of compartment syndrome (CS)

increases; therefore, also increases the possibility of

fas-ciotomies. Astudywaspublishedexploringthe association

betweenthesiteoftraumapenetrationtothelower

extrem-ity and the need for fasciotomies. Its authors concluded

thatproximallesionsbelowthekneeconfer asubstantially

increasedriskof“compartment”andthattheriskincreases

withanassociation withaproximaltibialfracture.7 _In_our

study,weshowedradiographicallyafractureofproximaltibial

metaphysisand ofproximalfibularepiphysiswith

involve-mentofthekneejoint.

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rev bras ortop.2014;49(1):86–88

CSisdefinedastheincreaseinpressurewithinthe

com-partmentenclosedbyfascia andwhichaffectstheviability

ofthetissues.AcuteCSisasevereconditionandoccursasa

resultoftraumawhich,inmanycases,requiredecompression

fasciotomiestopreventmusclenecrosis.2

Thedegreeofdamagewilldependonhowfastthepressure

riseisestablishedandhowlongitlasts.Thepathogenesisis

explainedbythehighintracompartmentalpressure,atlevels

sufficienttocompromisethemicrocirculationoftissues.8

Classicallytherearesixclinicalfindingsinthediagnosis

ofcompartmentsyndrome:(1)painintheaffectedextremity,

disproportionatetotheinjury;(2)paininducedbythe

stretch-ingofthecompartmentmuscles;(3)paresisofthemuscles

ofthe compartment;(4)hypoesthesiaorparesthesiainthe

topographyofthenervesthatrunthroughtheaffected

seg-ment;(5)hardeningorinflammation,orboth,oftheaffected

site; and (6) reduced or absent distal pulses.9 _The _most

importantclinicalfindingishardening,strainintheaffected

segment(ifaccompaniedbypain),swelling,decreased

sensi-tivityanddifficultyinmovingthelimb.10

Inthelaboratoryworkup,anincreasedcreatinekinase(CK)

to 1000–5000U/ml is possible,which demonstrates a

myo-globinuriathatmaysuggestthediagnosis.9_The_patient_came

toourservice afterfracture manipulationforfixation with

L-plate,becausetherightlegdevelopedswellingand

progres-sivepaininalocalizedcompartment,andadecompressive

fasciotomy was indicated, based on leg nerve paresthesia

associatedwith limb volume, when comparedto the

con-tralaterallimb.Furthermore,atotalCK=637U/Lwasobtained,

whichconfirmedthediagnosis.

Absoluteindicationsforsurgicaltreatmentareopen

frac-turesandfracturesassociatedwithCSorvascularinjury.In

thesesituations,thetreatmentshould beconductedon an

emergencybasis.Inothercases,thetimeofsurgeryisdictated

bythegeneralclinicalconditionofthepatient.6

Conclusion

Thefractureofthetibialplateauisamajortrauma,which

maybeassociatedwithpoorprognosis.Thus,becauseofthe

importanceoftheassociationbetweenbonefracturesandthe

developmentofcompartmentsyndrome,theestablishment

ofthedifferentialdiagnosis isessential,basedontheearly

recognitionofthesignsandsymptomsofthesyndromefor

theinstitutionofanappropriatetherapy,whichimprovesthe

prognosisanddecreasesthemorbidity.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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