Compartment Syndrome Associated with Tibial Fracture* 1

Transcription

1 Compartment Syndrome Associated with Tibial Fracture* 1 BY PAUL TORNETTA, III, M.D4, BROOKLYN, NEW YORK, AND DAVID TEMPLEMAN, M.D.ij, MINNEAPOLIS, MINNESOTA An Instructional Course Lecture, The American Academy of Orthopaedic Surgeons Compartment syndrome is a well recognized complication of a fracture of the tibial shaft Despite attempts to document the pathophysiology of compartment syndrome, the clinical recognition of this disorder is frequently difficult. If left untreated, compartment syndrome not only results in the loss of nerve and muscle function but also may lead to infection, myoglobinuria and renal failure, and even amputation. A closed tibial fracture is one of the conditions most frequently associated with the development of compartment syndrome. Compartment syndrome occurs after both closed and open tibial fractures; the prevalence has ranged from five (1 per cent) of 411 fractures to eighteen (9 per cent) of 198 fractures 3. The range probably reflects the varying percentage of high-velocity injuries seen at different medical centers 31. The Clinical Problem Despite an increased sensitivity of clinicians to the diagnosis of compartment syndrome, few criteria are available to serve as guidelines for making the diagnosis. The subjective criteria include pain, sensory changes, motor function, and turgor, but the sole objective criterion is the measurement of intracompartmental pressures. However, even the definition of abnormal tissue pressure is difficult, as anatomical compartments are not homogeneous and an equilibrium of pressure cannot be expected 18. Heckman et al. s measured intracompartmental pressures at multiple sites in patients who had a tibial fracture. They documented localized areas of increased tissue pressure within single compartments. *Printed with permission of The American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 46, The American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March tno benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. ^Department of Orthopaedics, University Hospital, 450 Clarkson Avenue, Box 30, Brooklyn, New York address: PTornetta@mem.po.com. Department of Orthopaedic Surgery, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota These differences were significant (p < ) at distances of as little as five centimeters from the site of the fracture. In twenty-four of the twenty-five patients, the highest pressures were found in the anterior and posterior compartments. Those authors recommended the measurement of pressure at multiple sites, especially at the level of the fracture, and the careful assessment of all compartments 8. For the clinician, the fundamental problem is the inability to identify the pressure at which nerve and muscle become ischemic. There is no reliable objective method to determine when a fasciotomy is required. Despite the development of various techniques for the measurement of intracompartmental pressure, it is not appropriate to rely on this measurement only; the diagnosis of a compartment syndrome is made from a constellation of clinical findings. The clinician should consider several key points when evaluating a patient for the development of compartment syndrome: (1) intracompartmental pressures are not a measure of muscle and nerve ischemia; (2) the development of muscle ischemia depends on the magnitude and duration of the elevated pressure; and (3) the tolerance of muscle to ischemia may vary among patients because of associated conditions such as shock, compensatory hypertension, or altered tone of the resistance vessels. Many researchers have tried to identify a critical value for intracompartmental pressure that will lead to the development of tissue necrosis if no treatment is given. Probably because of the variable factors just mentioned, different critical values have been identified by various authors 37 " 1519 ' 23 ' 32. There have been two approaches to the problem of a critical value. Some investigators have tried to identify an absolute tissue pressure above which the risk of tissue necrosis is great enough that a fasciotomy should be performed. This value has been determined to be thirty 3723 or forty-five 19 millimeters of mercury (4.00 or 6.00 kilopascals). Others have suggested that the critical value must reflect a decrease in tissue perfusion, which occurs when the intracompartmental pressure approaches the perfusion 1438 THE JOURNAL OF BONE AND JOINT SURGERY

2 COMPARTMENT SYNDROME ASSOCIATED WITH TIBIAL FRACTURE 1439 pressure, as reflected by some measurement of the systemic blood pressure 911. This critical difference between blood pressure and compartmental pressure, or differential pressure (AP or DP), has been suggested to be thirty 1 " 532 to forty" millimeters of mercury (4.00 to 5.33 kilopascals). Diagnosis The mechanism of injury is the first indication that a patient may be at risk for a compartment syndrome. Chapman 4 estimated the amount of energy associated with various mechanisms of tibial fracture: a fall was associated with 136 newton-meters of energy, whereas an injury caused by the bumper of a motor vehicle striking a pedestrian was associated with as much as 135,600 newton-meters of energy. According to Tscherne and Gotzen 31, the more severe the initial soft-tissue injury, the greater the probability that soft-tissue complications, including compartment syndrome, will develop. Because the development of a compartment syndrome is unpredictable, close observation is required until the acute swelling begins to subside. A single examination of a patient who has a tibial fracture may not reveal a compartment syndrome, which may develop hours or days after the initial injury. Severe or increasing pain, tightness in the leg, and sensory changes are frequently the first symptoms. All complaints should be thoroughly investigated. A careful physical examination is necessary and should include testing of muscle strength in the leg and foot as well as sensory testing of the superficial and deep peroneal nerves and the tibial nerve. Because nerve tissue is very sensitive to ischemia, sensory changes frequently herald the onset of decreased tissue perfusion. Matsen 18 created a model to explain the development of compartment syndrome. This model was based on the premise that when local blood flow is unable to meet the metabolic demands of the tissue, ischemia begins. When tissue pressure increases, the intraluminal venous pressures within the compartment increase. This increase in venous pressure reduces the magnitude of the arteriovenous pressure gradient, which in turn reduces the blood flow to the tissues of the compartment. Both the magnitude and the duration of increased tissue pressure adversely affect the perfusion of the compartment. For example, it takes longer for a lower tissue pressure to adversely affect perfusion than it does for a higher tissue pressure, which quickly reduces the amount of blood flowing into the compartment. Although the measurement of intracompartmental pressure is a critical step in the evaluation of a patient who is suspected of having a compartment syndrome, the interpretation of the results raises several points of controversy. As already discussed, either an absolute value of intracompartmental pressure or the difference between the diastolic blood pressure and the intracompartmental pressure (which is used to identify a perfusion pressure) has been used by some as an indication to perform a fasciotomy 3 ' 7 ' 11 "' 9 ' 2 " 2. McQueen et al recently reported on the use of a differential pressure of less than thirty millimeters of mercury (4.00 kilopascals) as the threshold for a fasciotomy. With use of this criterion, three of 116 patients with a tibial fracture had a fasciotomy and none of the 116 patients were observed to have sequelae 15. Several patients had an absolute intracompartmental pressure of greater than forty millimeters of mercury (5.33 kilopascals) but were simply observed because the differential pressure was more than thirty millimeters of mercury (4.00 kilopascals). The authors concluded that simple observation was safe, even when the absolute compartmental pressure was high, if the diastolic pressure remained high enough to perfuse the compartment Compartment Syndrome and Tibial Nailing In 1971, Hamza et al. 6 reported on fifty patients who had nailing with reaming because of a tibial fracture; there were five neuromuscular complications that, in retrospect, seem to have been the consequences of a compartment syndrome. Two patients had clawing of the toes, two had a transient peroneal-nerve palsy, and one had an equinus contracture. More recently, Koval et al. 14 retrospectively reviewed the records concerning sixty acute fractures of the tibia that had been treated with nailing and reaming with the limb in the position on a fracture-table. The purpose of that report was to delineate clearly the complications associated with tibial nailing with reaming. The average time from the injury to the operation was ten days. The authors found that eighteen of the sixty fractures were associated with neurological complications, which included paresthesias in the distribution of the peroneal nerve (eleven lower extremities), foot drop (three lower extremities), and combined sensory and motor deficits (four lower extremities). Sixteen of these eighteen neurological manifestations were transient; the foot drop persisted in one patient and the peroneal paresthesias persisted in another. The specific cause of these neurological problems could not be determined, and many probably were multifactorial. The authors implicated several factors: the presence of soft-tissue swelling, bleeding into the compartment as a result of reaming, and the use of calcaneal traction. In such acute fractures, all of these factors may lead to increased intracompartmental pressures, resulting in neurological damage. Alternatively, this nerve damage may have resulted from traction or a compression injury to the nerve during the procedure. Several other investigators have specifically addressed the possible association between tibial nailing and the development of compartment syndrome. Tischenko and Goodman 29 reported on three patients in whom a compartment syndrome developed immediately after tibial nailing with reaming. They prospec- VOL. 78-A, NO. 9, SEPTEMBER 1996

3 1440 PAUL TORNETTA, 111, AND DAVID TEMPLEMAN tively studied an additional seven patients who had continuous monitoring of the pressure in the deep posterior compartment during nailing with reaming. Two peak pressures were seen: one during reduction of the fracture and the other during reaming. On the basis of these findings, they recommended that intracompartmental pressure should be monitored in patients for whom prolonged traction is needed intraoperatively. Compartment syndrome developed after nailing with reaming in three patients of Mawhinney et al. 21 and in two patients of Ho and Lau' 2. The common factors in these case reports were the use of reaming and the use of a posterior thigh-bar for positioning of the limb for longitudinal traction. McQueen et al.' 6 conducted a prospective study of intracompartmental pressures during and after tibial nailing with reaming. The pressure in the anterior compartment was continuously monitored before, during, and for twenty-four to thirty-six hours after the operation in sixty-six patients (sixty-seven fractures). In general, the pressure was seen to increase during the operative procedure and then to dissipate during the postoperative period. Peak pressures of more than thirty millimeters of mercury (4.00 kilopascals) were seen during traction and during reaming. The pressure decreased to a mean of twenty-three millimeters of mercury (3.07 kilopascals) within twenty-four to thirtysix hours after the procedure. A compartment syndrome developed in one patient postoperatively. The authors found no significant difference between the intracompartmental pressures that were measured during acute nailing procedures and those that were measured during delayed nailing procedures. There also were no significant differences among the intracompartmental pressures that were associated with the various types of fractures (as classified according to the system of Tscherne and Gotzen 31 ). McQueen et al." later reported that a compartment syndrome had developed in twentytwo (6.4 per cent) of 342 patients who were thirty-five years old or less. Because of the seemingly contradictory evidence in these clinical series, objective data must be evaluated. The development of compartment syndrome in two patients who had been managed with nailing with reaming prompted Moed and Strom 22 to study the pressures in the anterior and deep posterior compartments in dogs during and after nailing with reaming. The intracompartmental pressures increased during nailing with reaming and then returned to normal after fasciotomy in two of the ten dogs in the study group, whereas the intracompartmental pressures did not increase in any of the ten dogs in the control group (dogs that had a fracture but did not have nailing). The mean pressure was significantly higher (p < 0.05) in the anterolateral compartment of the dogs that had had intramedullary nailing, and this difference persisted for three hours postoperatively. No traction devices were used during the nailing procedures, which more strongly implicates reaming as the cause of the high intracompartmental pressures. In contrast, Tornetta and French 30 studied intracompartmental pressures during tibial nailing without reaming and without the use of continuous traction. They continuously monitored the pressure in the anterior compartment in thirty patients and found that the peak intracompartmental pressures occurred during manual reduction and during insertion of the nail. The pressure exceeded forty millimeters of mercury (5.33 kilopascals) in twelve of the thirty patients and was within thirty millimeters of mercury (4.00 kilopascals) of the diastolic blood pressure in fifteen. All of the increased pressures returned to baseline levels immediately after the nail had been inserted, and there were no residual neurological abnormalities in any of the fiftysix patients who had had no clinical signs of compartment syndrome when they were first seen. After evaluation of these studies, several conclusions can be made. First, acute compartment syndrome is seen after tibial nailing with reaming. Second, efforts should be made to avoid mechanical factors that may potentiate compartment syndrome. The most important factors that increase the intracompartmental pressure seem to be longitudinal traction, reaming, and the position of the lower limb. Shakespeare and Henderson 25 showed that, in patients who had an acute tibial fracture, the pressure in the deep posterior compartment increased 5.7 per cent per kilogram of weight applied for calcaneal traction. Wozasek et al. 34, in an experimental study in sheep, reported that the intramedullary pressure increased as much as tenfold during reaming. This increased pressure may cause extrusion of blood and marrow products through the fracture into the compartments. The position of the limb also must be considered. The standard position requires countertraction with the use of a posterior thigh-bar. The use of this bar can decrease arterial flow and venous return and contribute to ischemia of the leg. Matsen et al. 20 showed that, in three normal human subjects, elevation of the limb to the position decreased the tolerance to external pressure by thirty-five millimeters of mercury (4.67 kilopascals). Lastly, hemorrhagic shock decreases the mean arterial pressure and can be an important factor in the development of a compartment syndrome, particularly in a multiply injured patient. For these same reasons, a tourniquet should not be used for a patient who has a tibial fracture and is at risk for a compartment syndrome 35. These considerations should be understood by any surgeon who is planning a tibial nailing. When a compartment syndrome is clinically suspected, monitoring of the pressure in the anterior compartment near the site of the fracture may be helpful during and even after the nailing procedure. The indication for fasciotomy should be a pressure that is persistently within THE JOURNAL OF BONE AND JOINT SURGERY

4 COMPARTMENT SYNDROME ASSOCIATED WITH TIBIAL FRACTURE 1441 thirty millimeters of mercury (4.00 kilopascals) of the diastolic blood pressure, as recommended by McQueen and Court-Brown 15. Use of this guideline will allow the surgeon to avoid many unnecessary fasciotomies that would be done on the basis of a raw measurement of pressure alone. Transient elevations should not be considered evidence of compartment syndrome, as they are common and are not associated with sequelae Operative Technique for Fasciotomy To perform an adequate fasciotomy, we use extensive incisions that approximate the proximal-to-distal length of the compartment to be decompressed. A long fasciotomy is required for reliable decompression of an acute compartment syndrome 5. We do not recommend the use of a short incision that does not span the length of the compartment. Adequate decompression of the four fascial compartments of the leg can be achieved with either one or two incisions. Regardless of the approach used, all four compartments of the leg must be thoroughly decompressed. We recommend that all of the compartments be decompressed at the time of the initial fasciotomy because after one compartment has been released, hyperemia may precipitate increased pressures in adjacent compartments. If the anterior tibial artery was injured at the time of the tibial fracture, the anterior skin bridge created by the two-incision technique survives only as a fasciocutaneous flap. Because the acceptable length-towidth ratio for this type of flap may be exceeded, the skin bridge, particularly if it has been injured, may be placed in jeopardy when the two-incision technique is used. Matsen et al." J modified the single lateral incision advocated by Kelly and Whitesides 13, who performed decompression by fibulectomy. (We do not believe that the fibula should be removed during the treatment of a tibial fracture.) With this modified method 19, the incision is made from the fibular neck to the lateral malleolus. The skin is then retracted to expose and decompress the anterior, peroneal, and superficial posterior compartments. The deep posterior compartment is exposed by retraction of the peroneal compartment anteriorly and release of the soleus from the fibula to reveal the fascia. In most instances, the two-incision technique affords better exposure of the four compartments, and release of the soleus from the fibula is not required. A lateral incision is made over the intermuscular septum between the anterior and lateral compartments to release these two compartments. The medial incision is made two centimeters from the medial crest of the tibial shaft. The superficial posterior compartment is easily exposed by retraction of the skin. After the superficial posterior compartment has been released, the deep posterior compartment is exposed by retraction of the superficial compartment posteriorly. The interval between the superficial and deep compartments is best identified in the distal one-third of the leg where the gastrocnemius-soleus unit becomes tendinous. The deep posterior compartment should be released throughout its entire length. After the fasciotomy, a bulky compression dressing and a splint are applied. The foot should be placed in slight dorsiflexion to prevent an equinus contracture. The incision for the fasciotomy usually can be closed after three to five days. When two incisions have been made and it is not possible to close both, delayed primary closure of the medial wound should be performed. On the lateral side, where there is good muscle coverage over the bone, the wound may be closed by one of several methods involving the use of split-thickness skin grafts, relaxing incisions, or skin-stretching devices. Regardless of the method, excessive skin tension must be avoided with closure. It is important to understand the course of the superficial nerves, especially the divisions of the peroneal nerve, in relation to the techniques of fasciotomy, as these nerves can be damaged when the lateral incision is made. The common peroneal nerve originates from the sciatic nerve in the thigh. It enters the leg by passing anteriorly around the fibular head under the proximal portion of the peroneus longus muscle 33. The nerve then divides into the superficial and deep branches between the peroneus longus and the fibular neck. The deep peroneal nerve courses distally in the anterior compartment and supplies the muscles therein. The superficial peroneal nerve passes through the lateral compartment and supplies the peroneus brevis and longus muscles before it pierces the fascia in the distal third of the leg and terminates as the medial and intermediate dorsal cutaneous nerves of the foot. Recent attention has been given to the variations in the course of the superficial peroneal nerve and its cutaneous branches. Adkison et al. 1 studied the nerve in eighty-five legs from cadavera. In only sixty-two legs (73 per cent) did the nerve remain in the lateral compartment from its origin to its exit through the deep fascia, three to eighteen centimeters proximal to the lateral malleolus. In twenty-two legs (26 per cent), the nerve or one of its branches passed through the anterior compartment. In one leg (1 per cent), the nerve coursed directly beneath the deep fascia and superficial to the peroneus brevis and longus muscles. Great variation has also been found in the course of the cutaneous branches of the superficial peroneal nerve. Blair and Botte 2 recently reported that the most common pattern was a single nerve that exited the crural fascia at an average of twelve centimeters proximal to the ankle joint and then divided into its terminal branches approximately four centimeters proximal to the ankle joint. In the other patterns, the medial and intermediate dorsal cutaneous nerves arose independently from the superficial peroneal nerve and pierced VOL. 78-A, NO. 9, SEPTEMBER 1996

5 1442 PAUL TORNETTA, III, AND DAVID TEMPLEMAN FIG. 1-A FIG. 1-B Fig. 1-A: Illustration showing release of the compartments by division of the deep fascia of the anterior compartment first and then division of the intermuscular septum for release of the lateral compartment. Fig. 1 -B: Illustration showing the individual release of each compartment through its outer fascia (the preferred technique). the fascia separately; the intermediate dorsal cutaneous nerve penetrated the fascia at a more distal point in the leg than did the medial dorsal cutaneous nerve (usually within about six centimeters proximal to the ankle joint). The intermediate dorsal cutaneous nerve may be located anterior or posterior to the lateral malleolus and may remain in close proximity to it. The locations of the muscular branches of the peroneal nerve also have been more clearly delineated recently In addition to its recurrent, deep, and superficial branches, the common peroneal nerve was found to give off several muscular branches near the fibular neck. Most of these branches supplied the peroneus longus and extensor digitorum muscles. This leash of nerve fibers was located in the anterior compartment, two to five centimeters distal to the head of the fibula. An important implication of these recent anatomical studies relates to the technique used for the release of the anterior and lateral compartments. This can be done either by division of the deep fascia of one compartment and then division of the intermuscular septum for the release of the other compartment (Fig. 1-A) or by the individual release of each compartment through its outer fascia (Fig. 1-B). Because of the variable location of the superficial peroneal nerve within and crossing the anterior compartment, the second technique is safer. However, it must be remembered that the nerve may lie immediately beneath the fascia and therefore may be vulnerable to injury when this method is used. The terminal cutaneous branches of the superficial peroneal nerve are at risk at the distal end of the fasciotomy after they pierce the crural fascia, most commonly at the junction of the middle and distal thirds of the leg, approximately twelve centimeters proximal to the ankle. The intermediate dorsal cutaneous nerve is at particular risk if it crosses the fibula or lies too close to it. Likewise, care must be taken in the proximal region of the leg to avoid damage to the branches of the common peroneal nerve. Outcome of Compartment Syndrome When the diagnosis of a compartment syndrome is made early and a fasciotomy is performed promptly, most patients have few sequelae. Rorabeck and Macnab 24 documented that patients who had a release within six hours of the diagnosis had a full recovery, whereas those who had a release after six hours (mean time to operation, eighteen hours) had sequelae. In a study of the malpractice costs associated with a missed diagnosis of compartment syndrome in eight patients 28, the average indemnity was nearly $280,000. The sequelae included amputation and complete loss of function of the lower extremity. The costs were high because the patients were young (average age, sixteen years), with an average work-life expectancy of thirty years; thus, the loss of productivity in these patients was severe. Two factors were found to contribute to the missed diagnosis. First, intracompartmental pressure had not been measured in any of the patients. This points to the need for early diagnosis of a compartment syndrome and the timely measurement of intracompartmental pressure. Second, some patients had been evaluated by more than one physician as the syndrome evolved over a period of time. This demonstrates the need for improved communication between health-care providers in the assessment and observation of patients who are at risk for the development of a compartment syndrome. Overview A compartment syndrome of the leg may be a devastating complication of a tibial fracture. Meticulous and repeated examinations of the patient who has such a fracture are needed to ensure that the diagnosis is not THE JOURNAL OF BONE AND JOINT SURGERY

6 COMPARTMENT SYNDROME ASSOCIATED WITH TIBIAL FRACTURE 1443 missed. In patients who are conscious, sensory changes cially if reamers and prolonged traction are used usually occur before motor changes. Pain on passive In these situations, monitoring of the pressure in the stretching of the muscles in a given compartment may anterior compartment is a judicious step. If the nail is be the earliest clinical indicator 24. In patients who are inserted without the use of continuous traction or reamobtunded or anesthetized, objective criteria must be ing, incidental but short-lived increases in pressure will used to make the diagnosis. Intracompartmental pres- occur, but continuous monitoring is not needed 30. Once sure is the sole objective measurement and constitutes a compartment syndrome has been diagnosed, emeran indirect measurement of muscle and nerve ischemia, gent fasciotomy is needed to avoid permanent neuro- We believe that the most reliable measurement is the logical sequelae 24. Many techniques are available, but difference between the diastolic blood pressure and the regardless of the method chosen, all four compartments intracompartmental pressure (differential pressure, or must be released throughout their entire extent. A delay AP), and we consider a differential pressure of less than of more than six hours in the diagnosis or the fasciotomy thirty millimeters of mercury (4.00 kilopascals) to be usually leads to permanent weakness. The surgeon must indicative of compartment syndrome. Patients who are have a high index of suspicion for compartment synmanaged with tibial nailing are at particular risk, espe- drome for all patients who have a tibial fracture. References 1. Adkison, D. P.; Bosse, M. J.; Gaccione, D. R.; and Gabriel, K. R.: Anatomical variations in the course of the superficial peroneal nerve. J. Bone and Joint Surg., 73-A: , Jan Blair, J. M., and Botte, M. J.: Surgical anatomy of the superficial peroneal nerve in the ankle and foot. Clin. Orthop., 305: , Blick, S. S.; Brumback, R. J.; Poka, A.; Burgess, A. R.; and Ebraheim, N. A.: Compartment syndrome in open tibial fractures. J. Bone and Joint Surg., 68-A: , Dec Chapman, M. W.: Fractures of the tibial and fibular shafts. In Surgery of the Musculoskeletal System, edited by C. McC. Evarts. Vol. 3, pp. 8:5-8:62. New York, Churchill Livingstone, Gaspard, D. J., and Kohl, R. D., Jr.: Compartmental syndromes in which the skin is the limiting boundary. Clin. Orthop., 113: 65-68, Hamza, K. N.; Dunkerley, G. E.; and Murray, C. M.: Fractures of the tibia. A report on fifty patients treated by intramedullary nailing../. Bone and Joint Surg., 53-B(4): , Hargens, A. R.; Romine, J. S.; Sipe, J. C; Evans, K. L.; Mubarak, S. J.; and Akeson, W. H.: Peripheral nerve-conduction block by high muscle-compartment pressure. J. Bone and Joint Surg., 61 -A: , March Heckman, M. M.; Whitesides, T. E., Jr.; Grewe, S. R.; and Rooks, M. D.: Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the site of the fracture. / Bone and Joint Surg., 76-A: , Sept Heckman, M. M.; Whitesides, T. E., Jr.; Grewe, S. R.; Judd, R. L.; Miller, M.; and Lawrence J. H., Ill: Histologic determination of the ischemic threshold of muscle in the canine compartment syndrome model./ Orthop. Trauma, 7: , Heppenstall, R. B.; Scott, R.; Sapega, A.; Park, Y. S.; and Chance, B.: A comparative study of the tolerance of skeletal muscle to ischemia. Tourniquet application compared with acute compartment syndrome. J. Bone and Joint Surg., 68-A: , July Heppenstall, R. B.; Sapega, A. A.; Scott, R.; Shenton, D.; Park, Y. S.; Maris, J.; and Chance, B.: The compartment syndrome. An experimental and clinical study of muscular energy metabolism using phosphorous nuclear magnetic resonance spectroscopy. Clin. Orthop., 226: , Ho, Y. K., and Lau, P. Y.: Compartment syndrome after intramedullary interlocking nailing of a tibial fracture. Injury, 22: , Kelly, R. P., and Whitesides, T. E., Jr.: Transfibular route for fasciotomy of the leg [abstract]../. Bone and Joint Surg., 49-A: , July Koval, K. J.; Clapper, M. F.; Brumback, R. J.; Ellison, P. S., Jr.; Poka, A.; Bathon, G. H.; and Burgess, A. R.: Complications of reamed intramedullary nailing of the tibia./ Orthop. Trauma, 5: , McQueen, M. M., and Court-Brown, C. M.: Compartment monitoring in tibial fractures. The pressure threshold for decompression. / Bone and Joint Surg., 78-B(l): , McQueen, M. M.; Christie, J.; and Court-Brown, C. M.: Compartment pressures after intramedullary nailing of the tibia. / Bone and Joint Surg., 72-B(3): , McQueen, M. M.; Christie, J.; and Court-Brown, C. M.: Acute compartment syndrome in tibial diaphyseal fractures. / Bone and Joint Swrg., 78-B(l): 95-98, Matsen, F. A., Ill: Compartment syndromes. Part A. Pathophysiology of compartment syndromes. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 38, pp Park Ridge, Illinois, The American Academy of Orthopaedic Surgeons, Matsen, F. A., Ill; Winquist, R. A.; and Krugmire, R. B., Jr.: Diagnosis and management of compartmental syndromes. / Bone and Joint Surg., 62-A: , March Matsen, F. A., Ill; Mayo, K. A.; Krugmire, R. B., Jr.; Sheridan, G. W.; and Kraft, G. H.: A model compartmental syndrome in man with particular reference to the quantification of nerve function. / Bone and Joint Surg., 59-A: , July Mawhinney, I. N.; Maginn, P.; and McCoy, G. F.: Tibial compartment syndromes after tibial nailing../. Orthop. Trauma, 8: , Moed, B. R., and Strom, D. E.: Compartment syndrome after closed intramedullary nailing of the tibia: a canine model and report of two cases. / Orthop. Trauma, 5: 7] -77, Mubarak, S. J.; Owen, C. A.; Hargens, A. R.; Garetto, L. P.; and Akeson, W. H.: Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter./ Bone and Joint Surg., 60-A: , Dec Rorabeck, C. H., and Macnab, I.: The pathophysiology of the anterior tibial compartmental syndrome. Clin. Orthop., 113: 52-57, Shakespeare, D. T., and Henderson, N. J.: Compartmental pressure changes during calcaneal traction in tibial fractures. / Bone and Joint Surg., 64-B(4): ,1982. VOL. 78-A, NO. 9, SEPTEMBER 1996

7 1444 PAUL TORNETTA, III, AND DAVID TEMPLEMAN 26. Soejima, O.; Ogata, K.; Ishinislii, T.; Fukahori, Y.; and Miyauchi, R.: Anatomic considerations of the peroneal nerve for division of the fibula during high tibial osteotomy. Orthop. Rev., 23: , Stitgen, S. H.; Cairns, E. R.; Ebraheim, N. A.; Niemann, J. M.; and Jackson, W. T.: Anatomic considerations of pin placement in the proximal tibia and its relationship to the peroneal nerve. Clin. Orthop., 278: , Templeman, D.; Schmidt, R. D.; and Varecka, T. F.: The economic costs of missed compartment syndromes. Orthop. Trans., 17: 989, Tischenko, G. J., and Goodman, S. B.: Compartment syndrome after intramedullary nailing of the tibia../. Bone and Joint Surg., 72-A: 41-44, Jan Tornetta, P., Ill, and French, B.: Compartment pressures during unreamed tibial nailing without traction. Read at the International Symposium for Minimal Invasive Traumatology, Salzburg, Austria, Feb. 10, Tscherne, H., and Gotzen, L.: Fractures with Soft Tissue Injuries. New York, Springer, Whitesides, T. E., Jr.; Haney, T. C; Morimoto, K.; and Harada, H.: Tissue pressure measurements as a determinant for the need of fasciotomy. Clin. Orthop., 113:43-51, Woodburne, R. T.: Essentials of Human Anatomy. Ed. 7, pp New York, Oxford University Press, Wozasek, G. E.; Simon, P.; Redl, H.; and Schlag, G.: Intramedullary pressure changes and fat intravasation during intramedullary nailing: an experimental study in sheep./ Trauma, 36: , Zweifach, S. S.; Hargens, A. R.; Evans, K. L.; Smith, R. K.; Mubarak, S. J.; and Akeson, W. H.: Skeletal muscle necrosis in pressurized compartments associated with hemorrhagic hypotension. J. Trauma, 20: , THE JOURNAL OF BONE AND JOINT SURGERY