The incidence of compartment syndrome after flexible nailing of pediatric tibial shaft fractures

Abstract

Purpose Pediatric tibial shaft fractures are common injuries encountered by the orthopaedic surgeon. Flexible intramedullary nailing has become popular for pediatric patients with tibial shaft fractures that require operative fixation. The purpose of our study was to evaluate the incidence of, and the risk factors for, compartment syndrome (CS) after flexible intramedullary nailing of these injuries. Methods A retrospective review of tibial shaft fractures treated consecutively with flexible intramedullary nailing at our institution from 2003 to 2010 was performed. The incidence of CS after flexible nailing was recorded. In addition, age, weight, mechanism of injury, polytrauma, presence of an open fracture, presenting neurovascular exam, fracture pattern, delay in treatment ([24 h from injury), prior closed reduction attempts, method of reduction (open vs. closed) in the operating room, total fluoroscopy time, and operative time were recorded. Comparisons were made between children who developed CS and those who did not. Results Thirty-one children met inclusion criteria with a mean age of 11.2 years (range, 6.3-15.3 years); all were boys. Nearly, 20% of children developed CS after flexible nailing of their fractures. Those who developed CS after flexible nailing were heavier than the unaffected group (52.6 ± 14.5 kg vs. 39.4 ± 15.2 kg, P = 0.05); with a greater percentage of children 50 kg or greater (83.3% vs. 26.1%, P = 0.02) within the CS group. Children who developed CS were also more likely to present with neurologic deficits in the absence of compartmental swelling prior to surgery (66.7% vs. 9.1%, P = 0.009), and more likely to have comminuted/complex fracture patterns (83.3% vs. 29.1%, P = 0.02). There was no difference between patients who did and did not develop CS in regards to age (P = 0.42), high-energy injury mechanism (P = 0.30), polytrauma (P = 1.0), delay in treatment (P = 0.28), prior closed reduction attempts (P = 1.0), method of reduction (open vs. closed; P = 1.0) in the operating room, total fluoroscopy time (P = 0.96), and total operative time (P = 0.45). In addition, there was no difference (P = 0.65) in the rates of CS between children with open and closed fractures. Conclusions There is a high risk of CS after flexible intramedullary nailing of pediatric tibial shaft fractures regardless of whether an injury is open or closed. Variables that would seemingly be associated with the development of CS (high-energy injury mechanisms, polytrauma, treatment delay, prior closed reduction attempts, and closed reduction in the operating room) were not statistically associated with CS in our study. Clinicians should be wary for the development of CS whenever utilizing flexible nails for tibial shaft fractures, especially when the following co-morbidities are present: the child weighs greater than 50 kg, has complex/comminuted fracture patterns, or has a neurologic deficit in the absence of compartmental swelling prior to operative intervention.

Flexible Intramedullary Nailing of Unstable and/or Open Tibia Shaft Fractures in the Pediatric Population

“…Finally, a well-documented preoperative neurovascular examination is critical as preexisting neurovascular deficits in the absence of compartmental swelling may serve as an early warning sign of potential compartment syndrome after flexible nailing. 17 …”

Tibial shaft fractures in adolescents

“…However, it has been the authors' experience that older children with a closed tibial shaft fracture can be prone to delayed union and incomplete healing, which may lead to prolonged restrictions from activities and sports. Whereas flexible nail fixation has increased in popularity for the treatment of these fractures [2][3][4][5], significant complications such as compartment syndrome, malunion, nonunion, and nail migration have been reported [6,7], and casting currently remains the mainstay of treatment at most institutions [8]. The purpose of this study was to analyze success and failure of cast treatment for closed tibial diaphyseal fractures in the adolescent population.…”

The effect of two different surgical methods on intracompartmental pressure values in tibial shaft fractures: An experimental study in a rabbit model

“…This method may be similar to flexible intramedullary nailing of long bone fractures. In recent studies, [20,30] flexible intramedullary nailing of long bone fractures has been shown to have high risk for development of ACS in pediatric population. The reason may be soft-tissue trauma caused by multiple attempts to reduce the fracture and pass the nail.…”

“…In addition, it was reported in a recent study that ACS can also develop in pediatric tibial shaft fracture treated with flexible IMP. [20] Clinical observation has demonstrated that edema in tibial shaft fracture dissolves day after treatment with ICF; however there is no study investigating ICP measurements after application of ICF for tibial shaft fracture. ICP monitoring after IMP in such fracture has been well documented.…”