RESUMO
OBJECTIVE: To determine the correlation between the OTA/AO classification of tibia fractures and the development of acute compartment syndrome (ACS). DESIGN: Retrospective review of prospectively collected database. SETTING: Single Level 1 academic trauma center. PATIENTS: All patients with a tibia fracture from 2006 to 2016 were reviewed for this study. Three thousand six hundred six fractures were initially identified. Skeletally mature patients with plate or intramedullary fixation managed from initial injury through definitive fixation at our institution were included, leaving 2885 fractures in 2778 patients. METHODS: After database and chart review, univariate analyses were conducted using independent t tests for continuous data and χ tests of independence for categorical data. A simultaneous multivariate binary logistic regression was developed to identify variables significantly associated with ACS. RESULTS: ACS occurred in 136 limbs (4.7%). The average age was 36.2 years versus 43.3 years in those without (P < 0.001). Men were 1.7 times more likely to progress to ACS than women (P = 0.012). Patients who underwent external fixation were 1.9 times more likely to develop ACS (P = 0.003). OTA/AO 43 injuries were at least 4.0 times less likely to foster ACS versus OTA/AO 41 or 42 injuries (P < 0.007). OTA/AO 41-C injuries were 5.5 times more likely to advance to ACS compared with OTA/AO 41-A (P = 0.03). There was a significantly higher rate of ACS in OTA/AO 42-B (P = 0.005) and OTA/AO 42-C (P = 0.002) fractures when compared with OTA/AO 42-A fractures. In the distal segment, fracture type did not predict the risk of ACS (P > 0.15). Group 1 fractures had a lower rate of ACS compared with group 2 (P = 0.03) and group 3 (P = 0.003) fractures in the middle segment only. Bilateral tibia fractures had a 2.7 times lower rate of ACS (P = 0.04). Open injury, multiple segment injury, fixation type, and concurrent pelvic or femoral fractures did not predict ACS. CONCLUSIONS: In this large cohort of tibia fractures, we found that the age, sex, and OTA/AO classification were highly predictive for the development of ACS. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Síndrome do Compartimento Anterior/etiologia , Fixação Interna de Fraturas/efeitos adversos , Fraturas da Tíbia/classificação , Fraturas da Tíbia/cirurgia , Doença Aguda , Adulto , Distribuição por Idade , Síndrome do Compartimento Anterior/epidemiologia , Síndrome do Compartimento Anterior/fisiopatologia , Estudos de Coortes , Bases de Dados Factuais , Feminino , Fixação Interna de Fraturas/métodos , Consolidação da Fratura/fisiologia , Humanos , Incidência , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Distribuição por Sexo , Fraturas da Tíbia/diagnóstico por imagem , Adulto JovemRESUMO
BACKGROUND: Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients. METHODS: A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded. RESULTS: Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common. CONCLUSIONS: Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected without a significant effect on final outcome. Finally, there is a need for longer follow-up to determine long-term outcomes. LEVEL OF EVIDENCE: Level III-systematic review of level III/IV studies.
Assuntos
Fraturas Intra-Articulares/epidemiologia , Traumatismos do Joelho/epidemiologia , Osteocondrose/epidemiologia , Fraturas da Tíbia/epidemiologia , Adolescente , Síndrome do Compartimento Anterior/epidemiologia , Criança , Comorbidade , Feminino , Fixação Interna de Fraturas/métodos , Consolidação da Fratura , Humanos , Articulação do Joelho , Masculino , Redução Aberta/métodos , Ligamento Patelar/lesões , Complicações Pós-Operatórias/epidemiologia , Amplitude de Movimento Articular , Traumatismos dos Tendões/epidemiologia , Fraturas da Tíbia/cirurgia , Lesões do Menisco Tibial/epidemiologia , Resultado do TratamentoRESUMO
BACKGROUND: We sought to examine the occurrence of acute compartment syndrome (ACS) in the cohort of patients with tibial diaphyseal fractures and to detect associated risk factors that could predict this occurrence. MATERIALS AND METHODS: A total of 1,125 patients with tibial diaphyseal fractures that were treated in our centre were included into this retrospective cohort study. All patients were treated with surgical fixation. Among them some were complicated by ACS of the leg. Age, gender, year and mechanism of injury, injury severity score (ISS), fracture characteristics and classifications and the type of fixation, as well as ACS characteristics in affected patients were studied. RESULTS: Of the cohort of patients 772 (69 %) were male (mean age 39.60 ± 15.97 years) and the rest were women (mean age 45.08 ± 19.04 years). ACS of the leg occurred in 87 (7.73 %) of all tibial diaphyseal fractures. The mean age of those patients that developed ACS (33.08 ± 12.8) was significantly lower than those who did not develop it (42.01 ± 17.3, P < 0.001). No significant difference in incidence of ACS was found in open versus closed fractures, between anatomic sites and following IM nailing (P = 0.67). Increasing pain was the most common symptom in 71 % of cases with ACS. CONCLUSIONS: We found that younger patients are definitely at a significantly higher risk of ACS following acute tibial diaphyseal fractures. Male gender, open fracture and IM nailing were not risk factors for ACS of the leg associated with tibial diaphyseal fractures in adults. LEVEL OF EVIDENCE: Level IV.
Assuntos
Síndrome do Compartimento Anterior/epidemiologia , Fraturas da Tíbia/complicações , Adulto , Síndrome do Compartimento Anterior/diagnóstico , Síndrome do Compartimento Anterior/terapia , Diáfises , Feminino , Fixação Interna de Fraturas , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fraturas da Tíbia/diagnóstico , Fraturas da Tíbia/cirurgia , Adulto JovemRESUMO
BACKGROUND: Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier wants to continue training, there is no proven effective nonoperative treatment, and fasciotomy of 1 or more of the lower leg muscle compartments is usually recommended. Our clinical protocol differs from most reported ones in the use of the forefoot rise test to increase pressure and provoke pain and our recommending minimal surgery of the anterior compartment only. We present results of surgery based on our clinical management flowchart. METHODS: Patients who had surgery during a 12-year period were reviewed by telephone interview or office examination. Pain was graded from 0 (none) to 4 (unbearable). Preoperative resting and exercise anterior compartment pressures were evaluated in most subjects before and immediately following a repeated weight-bearing forefoot rise test. Surgery was under local anesthesia, limited to the anterior compartment only and percutaneous (excepting muscle hernias). There were 36 patients, mean age 24 years. RESULTS: Of 16 patients who were originally operated unilaterally, 5 patients were later operated on the other side. Mean presurgery resting pressure was 56 mm Hg (40-80 mm Hg) rising to 87 mm Hg (55-150 mm Hg) with exercise. Mean exercise pain score dropped from 2.9 presurgery to 1.3 postsurgery (n = 35, P < .0001). Complications included superficial peroneal nerve injury (3 legs in 3 patients, 1 requiring reoperation). CONCLUSION: When we used our clinical management flowchart based on the forefoot rise test, percutaneous fasciotomy of the anterior compartment alone provided good clinical results. Care must be taken to prevent injury to the superficial peroneal nerve in the distal lower leg. LEVEL OF EVIDENCE: Level IV, retrospective case series.
Assuntos
Síndrome do Compartimento Anterior/terapia , Hérnia/terapia , Esforço Físico , Adulto , Síndrome do Compartimento Anterior/diagnóstico , Síndrome do Compartimento Anterior/epidemiologia , Síndrome do Compartimento Anterior/cirurgia , Doença Crônica , Fasciotomia , Feminino , Hérnia/epidemiologia , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos , Estudos Retrospectivos , Suporte de Carga , Adulto JovemRESUMO
BACKGROUND: Chronic exertional compartment syndrome (CECS) is a common source of lower extremity pain in physically active military service members. While anatomic risk factors of CECS have been proposed, there is no existing study that evaluates the correlation of demographic and occupational risk factors and the overall incidence rate of CECS in an active military population. HYPOTHESIS: Young, enlisted service members in the United States (US) ground military forces would demonstrate higher incidence rates of CECS in the study population because of greater exposure to at-risk dismounted activity on the battlefield and in training. STUDY DESIGN: Cohort study (prevalence); Level of evidence, 2. METHODS: A retrospective study of all US active military service members with diagnosed nontraumatic exertional compartment syndrome of the lower extremity (code 729.72 in the International Classification of Diseases, 9th Edition) between 2006 and 2011 was performed using the Defense Medical Epidemiology Database. Demographic and occupational risk factors such as sex, age, race, branch of military service, and military rank were individually subcategorized, and cumulative and subgroup incidence rates of CECS were calculated using a multivariate Poisson regression model. RESULTS: A total of 4100 diagnosed cases of CECS were identified within an at-risk population of 8,320,201, which correlates to an incidence rate of 0.49 cases per 1000 person-years. The annual adjusted incidence rate of CECS increased from 0.06 cases per 1000 person-years in 2006 to 0.33 cases per 1000 person-years in 2009. Increasing chronological age, female sex, white race, junior enlisted rank, and Army service were significantly correlated with an elevated risk for CECS. CONCLUSION: This study systematically evaluated the epidemiology of CECS among an idealized subset at risk for this condition. Sex, age, race, military rank, and branch of service were all important factors associated with the incidence of CECS in this physically active population.
Assuntos
Síndrome do Compartimento Anterior/epidemiologia , Militares/estatística & dados numéricos , Adulto , Feminino , Humanos , Incidência , Masculino , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Acute lower extremity compartment syndrome (ALECS) is a devastating complication that often presents silently in critically injured patients; therefore, we developed a protocol to screen high-risk patients. METHODS: This prospective observational study included all Shock Trauma intensive care unit patients who met specific high-risk criteria including pulmonary artery catheter-directed shock resuscitation, open or closed tibial shaft fracture, major vascular injury below the aortic bifurcation, abdominal compartment syndrome, or pelvic or lower extremity crush injury. Patients were screened at admission and every 4 hours thereafter for the first 48 hours of admission. Screening included physical examination (PE) and anterior or deep posterior calf compartment pressure measurements when PE was suspicious or unreliable. A positive screening, defined as a DeltaP <30 mm Hg (where DeltaP is the difference between the diastolic blood pressure and the compartment pressure), mandated a four-compartment fasciotomy. RESULTS: During a 6-month period, the incidence of ALECS in screened patients was surprisingly high at 20% (9 patients). With diligent screening, it was diagnosed early in the patient's Shock Trauma intensive care unit course. These were patients with severe injuries with an Injury Severity Score of 32.0 +/- 12.5 who exhibited significant volume depletion, with a base deficit of 12.9 +/- 5.9 mEq/L and a lactate level of 13.0 +/- 5.2 mmol/L, requiring large volume resuscitation. Although aggressive fasciotomy resulted in no limb loss, ALECS was associated with an exceedingly high mortality rate at 67%. CONCLUSIONS: ALECS is an important clinical entity in critically injured patients with trauma associated with significant mortality. Aggressive screening may provide some diagnostic insight to those at risk.
Assuntos
Síndrome do Compartimento Anterior/diagnóstico , Síndrome do Compartimento Anterior/epidemiologia , Programas de Rastreamento/métodos , Ferimentos e Lesões/complicações , Resinas Acrílicas , Doença Aguda , Adolescente , Adulto , Síndrome do Compartimento Anterior/etiologia , Síndrome do Compartimento Anterior/cirurgia , Cuidados Críticos/métodos , Estado Terminal , Descompressão Cirúrgica/métodos , Feminino , Seguimentos , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Análise de Sobrevida , Centros de Traumatologia , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidadeRESUMO
Acute compartment syndrome is a serious complication of injury. It occurs when raised pressure within a closed osteofascial compartment compromises the circulation and function of tissues within the compartment. Most cases are caused by fracture. The largest group are tibial diaphyseal fractures, followed by soft tissue injury, crush syndrome, distal radial fractures and forearm diaphyseal fractures. Those at risk of developing acute compartment syndrome are young males, patients with bleeding disorders or on anticoagulant therapy and in the upper limb, high energy injury. The clinical symptoms and signs of acute compartment syndrome are pain, stretch pain and neurological abnormality, none of which are constantly present. Since early diagnosis of this condition is of paramount importance compartment monitoring is recommended. The recommended tissue pressure threshold for decompression has been variable through the years but should be related to the patient's blood pressure. A difference of less than 30 mmHg between the diastolic and tissue pressures has been validated clinically and it is recommended that at this level serious consideration should be given to decompression of the affected compartments. Use of this pressure threshold with compartment monitoring has been shown to half the delay to fasciotomy and significantly reduces the late complications of acute compartment syndrome.
Assuntos
Síndrome do Compartimento Anterior , Síndromes Compartimentais , Doença Aguda , Adulto , Síndrome do Compartimento Anterior/diagnóstico , Síndrome do Compartimento Anterior/epidemiologia , Síndrome do Compartimento Anterior/etiologia , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/epidemiologia , Síndromes Compartimentais/etiologia , Feminino , Traumatismos do Antebraço/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas do Rádio/complicações , Fatores de Risco , Lesões dos Tecidos Moles/complicações , Fraturas da Tíbia/complicaçõesRESUMO
Intramuscular pressure was measured with transducer-tipped catheters that had been inserted into the anterior and deep posterior compartments of the leg in seven healthy adults. Intramuscular pressure increased three to sevenfold (depending on the position of the ankle) in both compartments after the application of a plaster cast from the proximal part of the thigh to the malleoli. While the cast was in place, the baseline intramuscular pressure was elevated by the inflation of a tourniquet, which was located on the proximal part of the thigh, to a pressure of sixty millimeters of mercury (8.00 kilopascals). The intramuscular pressure in both the anterior and the deep posterior compartments was found to be lowest when the ankle joint was between the neutral and the resting positions (between 0 and 37 degrees of flexion). After the cast was bivalved and the opening on each side was spread approximately one-half centimeter, there was a significant decrease in intramuscular pressure of 47 per cent in the anterior compartment and of 33 per cent in the deep posterior compartment (p < 0.05 for both).