COMPARTMENT SYNDROME ON THE RIGHT LEG DUE TO CLOSED

FRACTURE OF THE RIGHT HEAD FIBULA AND CLOSED FRACTURE

OF THE RIGHT TIBIAL PLATEAU
HEMARTHROSIS ON THE RIGHT KNEE JOINT

IIN BANISWIRA C 111 08 193

Adviser:
dr. Muh. Ihsan Kitta
dr. A. Dhedie Prasatia Sam
dr. Yoga Data Satrya
dr. Prori Fatwa Noor
dr. Satria Prawira putra
Supervisor:
dr. Jainal Arifin, M.Kes, Sp.OT
Orthopaedic and Traumatology Department
Hasanuddin University
Makassar 2013

IDENTITY
Name
Age
Sex
Date of admittance
Reg

: Mr. S
: 48 years old
: Male
: July 11th 2013
: 61.84.64

HISTORY TAKING
Chief complaint : Pain at Right Leg

Suffered since 2 days before admitted to hospital due

to traffic accident
Mechanism of trauma The patient was riding a
motorcycle and then hit by a car from behind
History of unconscious (-), nausea (-), vomit (-)

GENERAL STATUS
Mild illness/well
nourished/composmentis
RR = 24x/min, symmetric, spontaneous,
thoracoabdominal type.
BP = 120/70mmHg, HR: 80 x/min,
regular, strong
T = 36.70 C

LOCALIZED STATUS
Right Knee region
I : Deformity (+), swelling (+), Hematoma (+), Wound
(-)
P : Tenderness (+), Ballotement (+)
ROM : Active and passive motion of the leg cannot be
evaluated due to pain
NVD : Sensibility is good , dorsalis pedis artery is
palpable, capillary refill time < 2 secs, extend big
toe (+)

Right Leg Region

I : Deformity (+), swelling (+), Hematoma (+), Wound
(-), Shiny skin (+), Bulla (+) at anterior middle
aspect
P : Tenderness (+), Passive strecthing pain (+)
ROM : Active and passive motion of the leg cannot be
evaluated due to pain
NVD : Sensibility is good , dorsalis pedis artery is
palpable, capillary refill time < 2 secs, extend big
toe (+)

CLINICAL PICTURE

Radiology

LABORATORY FINDINGS

WBC

11.700/uL

RBC

3.830.000 /uL

HGB

12.4 g/dl

HCT

46.4%

PLT

316.000/uL

Ur

20

Cr

1.4

SGOT

31

SGPT

21

BT

CT

PT

12.5

APTT

23.2

HBsAg

Negatif

Anti HCV

Negatif

RESUME
A 48 years old male, with chief complaint pain at the
right leg since 2 days ago before admitted to hospital due
to traffic accident
Right leg shows sign of deformity, swelling, hematoma,
shiny skin, bulla at anterior middle aspect and on
palpation was found tenderness and passive strecthing
pain.
Active and passive motion of the leg cannot be evaluated
due to pain, capillary refill time < 2 secs, extend big toe
(+)
Radiography shows fractures of the right head fibula and
1/3 proximal right tibia

 Compartment Syndrome on the right leg

due to Closed fracture of the right tibial

plateau and Closed fracture of the right
head fibula
Hemarthrosis on the right knee joint

TREATMENT
IVFD RL
Analgetic
Antibiotic
Plan for fasciotomy
Plan for external fixation

DISCUSSION
TIBIA PLATEAU FRACTURE

MECHANISM OF INJURY
Fractures of the tibial plateau occur in the setting of

varus or valgus forces coupled with axial loading

The direction and magnitude of the generated force,
age of the patient, bone quality, and amount of knee
flexion at the moment of impact determine fracture
fragment size, location, and displacement

Koval, Kenneth J.; Zuckerman, Joseph. Handbook of Fractures, 3rd Edition. 2006
Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures. 2001

CLINICAL EVALUATION
Neurovascular examination is essential, especially

with high-energy trauma. The peroneal nerve is

tethered laterally as it courses around the fibular
neck.
Hemarthrosis frequently occurs in the setting of a
markedly swollen.
Compartment syndrome must be ruled out,
particularly with higher-energy injuries.

Koval, Kenneth J.; Zuckerman, Joseph. Handbook of Fractures, 3rd Edition. 2006
Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures. 2001

CLASSIFICATION

Thompson, JC. Netters Concise Orthopaedic Anatomy 2nd Edition . 2009

Types I to III are low-energy injuries.

Types IV to VI are high-energy injuries.
Type I usually occurs in younger individuals and is

associated with medial collateral ligament injuries

Type III usually occurs in older individuals

Koval, Kenneth J.; Zuckerman, Joseph. Handbook of Fractures, 3rd Edition. 2006
Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures. 2001

TREATMENT
Nonoperative

nondisplaced or minimally
displaced fractures
Protected weight bearing
and early range of knee
motion
Isometric
quadriceps
exercises and progressive
passive, active-assisted, and
active range-of-knee motion
exercises

Operative

Instability >10 degrees of the

nearly extended knee compared to
the contralateral side
Open fractures
Compartment syndrome
Vascular injury

Koval, Kenneth J.; Zuckerman, Joseph. Handbook of Fractures, 3rd Edition. 2006
Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures. 2001

Complication

Early

Compartment
syndrome

Late

Joint stiffness
Infection
Malunion & nonunion
Deformity
Posttraumatic
Osteoarthritis
Peroneal nerve injury

Koval, Kenneth J.; Zuckerman, Joseph. Handbook of Fractures, 3rd Edition. 2006
Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures. 2001

COMPARTMENT SYNDROME

Definition
Compartment syndrome is a condition in which

raised pressure within a closed fascial space and can

reduces capillary perfusion below a level necessary
for tissue viability.

Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures 2001.

Introduction
Has been recognized since 1872 when Volkman first

described the contracture that is a common sequale.

Compartment Syndrome has been found wherever a

compartment is present :
Hand
Forearm
Upper arm
Lower Extremity

Jimenez A. Louis, Stapp D. Mickey, Compartment syndrome of the foot and leg

Epidemiology
Sex :

Compartment syndrome was diagnosed more often

in men than women
Vasculary injury
Fracture

70%

30%

Incidence

5% of all tibia fractures

0.25% of distal radius fractures
3% of forearm fracture
Up to 10% of displaced calcaneus fractures

Etiology
Constriction of compartment
2. Increased fluid content in compartment
3. External compression
1.

Thompson Jon C. Netters Concise Orthopaedic Anatomy 2nd Edition . 2009

COMPARTMENTS OF LEG

Mubarak Scott J. Acute Compartment Syndrome Effect Of Dermotomy on Fascial Decompression in the Leg. University of
California : San Diego
Jimenez A. Louis. Compartment Syndrome Of the Foot and Leg. Chapter 3

Pathophisiology

Clinical Diagnosis
The five P:

Pain out of proportion

Pallor
Pulselessness
Paresthesia
Paralysis

Jimenez A. Louis. Compartment Syndrome Of the Foot and Leg. Chapter 3

Tissue Pressure Measurements

1.

whiteside's Infusion Technique

2. Wick Catheter
3. Slit catheter

Normal Intracompartmental
pressure = 30 mmHg
Mabvuure Nigel Tapiwa. Acute Compartment Syndrome of the Limbs : Current Concepts and Management
Jimenez A. Louis. Compartment Syndrome Of the Foot and Leg. Chapter 3

Canale S. Terry. Campbells. Operative Orthopaedics 11th Edition.2008

Management
Performed decompression of intracompartment

pressure
Evaluate the changes of symptoms (5P) every 15
minutes. If there is no emendation for 2 hours after
extrication of the elastic bandage and cast, have to
undertake fasciotomy immediately
Placing the foot at the level of the heart
Skin graft may be required to closed the wound
after 48 - 72 hours
Canale S. Terry. Campbells. Operative Orthopaedics 11th Edition.2008

posterior-medial incision
Canale S. Terry. Campbells. Operative Orthopaedics 11th Edition.2008

Anterolateral incision

Complication
Permanent nerve injury
Loss of muscle function

Prognosis
complications can be minimized with rapid diagnosis

and fasciotomy.
prognosis is good if fasciotomy is done within 25
hours after onset

Thank you
for
your
THANK YOU
attention