Ogden Type I to III tibial tubercle fractures in skeletally immature patients: is routine anterior compartment fasciotomy of the leg indicated?

Purpose Determine the frequency of compartment syndrome of the leg after displaced, operatively treated modified Ogden I to III tibial tubercle fractures (TTFxs), evaluate the preoperative assessment and use of advanced imaging, and need for prophylactic fasciotomies. Methods Retrospective analysis of operatively treated, displaced modified Ogden I to III TTFxs, at our level 1 paediatric trauma centre between 2007 and 2019. Modified Ogden Type IV and V fracture patterns were excluded. Fracture patterns were determined by plain radiographs. Results There were 49 modified Ogden I to III TTFxs in 48 patients. None had signs nor symptoms of vascular compromise, compartment syndromes or impending compartment syndromes preoperatively. In all, 13 of the 49 fractures underwent anterior compartment fasciotomy at surgery; eight of the 13 had traumatic fascial disruptions, which were extended surgically. All incisions were primarily closed. There were no instances of postoperative compartment syndromes, growth arrest, leg-length discrepancy or recurvatum deformity postoperatively. All patients achieved radiographic union and achieved full range of movement. Conclusion The potentially devastating complications of compartment syndrome or vascular compromise following TTFx did not occur in this consecutive series of patients over 12 years. The presence of an intact posterior proximal tibial physis and posterior metaphyseal cortex (Modified Ogden TTFx Type I to III) may mitigate the occurrence of vascular injury and compartment syndrome. Plain radiographs appear appropriate as the primary method of imaging TTFxs, with use of advanced imaging as the clinical scenario dictates. Routine, prophylactic fasciotomies do not appear necessary in Ogden I to III TTFxs, but should be performed for signs and symptoms of compartment syndrome. Level of evidence Level IV

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Tibial Tubercle Fractures in Children and Adolescents

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00134 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0013

Author(s):

Daniel B. Haber ◽

Frances Tepolt ◽

Michael P. McClincy ◽

Leslie Kalish ◽

Mininder S. Kocher

Keyword(s):

Children And Adolescents ◽

Compartment Syndrome ◽

Clinical Outcomes ◽

Return To Sport ◽

Adolescent Male ◽

Tibial Tubercle ◽

Valuable Insight ◽

Type I ◽

Fractures In Children

Objectives: To report patient characteristics, fracture types, treatment methods, and clinical outcomes of children and adolescents treated for tibial tubercle fractures. Methods: Patients age 19 and under treated for tibial tubercle fractures at a single institution from 1995 to 2015 were identified and their medical records were retrospectively reviewed. Clinical and radiographic outcomes were reported for patients with a minimum follow up of 6 months. Associations were tested using Fisher’s exact test. Results: Two-hundred thirty seven tibial tubercle fractures were identified in 229 patients; 198 (86%) male. There were 139 (59%) left sided injuries. Mean age was 14.3 years (range 4.9 - 19.8). Mean body mass index (BMI) was 25. Osgood-Schlatters was identified in 72 (30%) cases and was most commonly associated with Ogden type I fractures (p<0.001). Two-hundred and four (86%) fractures occurred while participating in athletics, most commonly basketball (87, 43%). Of the 228 cases for which mechanism of injury was identified, 69 (30%) occurred while landing, 60 (26%) resulted from a direct blow to the knee, and 51 (22%) occurred while jumping. Ogden III fractures were most common (96, 41%) followed by Ogden I fractures (67, 28%). Initial treatment was surgical for 158 (67%) fractures, of which 58 (37%) underwent reoperation, 53 (34%) for hardware removal. Ogden I fractures were most commonly treated non-operatively (91%) and Ogden II-V fractures were most commonly treated operatively (89%, p<0.001). Elevated BMI was associated with Ogden II-V fractures (p=0.003) and injuries requiring operative treatment (p<0.001). Compartment syndrome was identified in 4 (2%) injuries and required emergent fasciotomy. Prophylactic anterior and/or lateral fasciotomy was performed in 35 (15%) operatively treated injuries. Of the 117 (49%) patients for whom minimum 6-month follow up was documented, 103 (88%) returned to sports; among those treated operatively (87), 2 (2%) developed symptomatic limb length discrepancy, 1 (1%) developed tibial recurvatum, and 6 (7%) developed post-operative infection. At last follow up, 39 (45%) of surgical patients reported pain at the tibial tubercle, 23 (26%) reported pain with squatting, and 13 (15%) had patellar tendonitis. Thirty-seven (43%) complained of hardware prominence. Conclusion: Tibial tubercle fractures occur most commonly in adolescent male athletes and are associated with basketball, elevated BMI, Osgood-Schlatters, and a risk of compartment syndrome. Following treatment, most patients return to sport. As the largest single series of tibial tubercle fractures reported, this study provides valuable insight into injury epidemiology, relationship with Osgood Schlatters, and clinical outcomes.

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TIBIAL TUBERCLE FRACTURES IN CHILDREN AND ADOLESCENTS

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00186 ◽

2019 ◽

Vol 7 (3_suppl) ◽

pp. 2325967119S0018

Author(s):

Daniel B. Haber ◽

Frances Tepolt ◽

Michael McClincy ◽

Leslie Kalish ◽

Mininder S. Kocher

Keyword(s):

Children And Adolescents ◽

Compartment Syndrome ◽

Patient Characteristics ◽

Tibial Tubercle ◽

Type I ◽

Return To Sports ◽

Type Iv ◽

Small Series ◽

Fractures In Children

Background: Tibial tubercle fractures are uncommon sports related injuries. Only small series are reported in the literature. The purpose of this study is to report patient characteristics, fracture types, treatment methods, and clinical outcomes of children and adolescents treated for tibial tubercle fractures. Methods: Patients age 18 and under treated for tibial tubercle fractures at a single institution from 1995 to 2015 were identified and their medical records were retrospectively reviewed. Clinical and radiographic outcomes were reported for patients with minimum follow up of 6 months. Results: Two-hundred thirty-six tibial tubercle fractures were identified in 228 patients, 198 (86%) of whom were males. Mean age was 14.3 years (range 7.7-17.6). Mean body mass index (BMI) was 25.0 (range 16.1-38.9). Osgood-Schlatter disease was identified in 72 (31%) cases and was most commonly associated with type I fractures (p<0.001). Two-hundred and three fractures (86%) occurred while participating in athletics, most commonly basketball (87, 43%). Thirty percent of fractures occurred while landing, 26% resulted from a direct blow to the leg, and 22% occurred while jumping. Type III fractures were most common (96, 41%) followed by type I fractures (67, 29%). Initial treatment was surgical for 157 (67%) fractures. Type I fractures were most commonly treated non-operatively (91%) and types II-V fractures were most commonly treated surgically (89%, p<0.001). Operative fractures were associated with higher BMI z-scores (mean 1.16, p=0.05) than those treated non-operatively. Compartment syndrome was identified in 4 (2%) patients, 3 of which were had type IV fractures. Eighty-eight percent of patients returned to sports. Among those treated operatively, 55% had hardware removed and 7% developed post-operative infection. At last follow up, 45% of surgical patients reported pain on palpation at the tibial tubercle and 26% reported pain with squatting. Conclusions: Tibial tubercle fractures are sports related injuries and occur most commonly in adolescent males. They are associated with Osgood-Schlatter disease, a higher than average BMI, and a small but relevant risk of compartment syndrome, particularly in type IV fractures. Whether treated surgically or non-surgically, most patients return to sports despite a high incidence of post-treatment pain at the tibial tubercle.

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Spontaneous Non-Traumatic Anterior Compartment Syndrome with Peroneal Neuropathy and Favorable Outcome

Neuropediatrics ◽

10.1055/s-2008-1073035 ◽

1994 ◽

Vol 25 (05) ◽

pp. 268-270 ◽

Cited By ~ 7

Author(s):

A. Sloane ◽

J. Vajsar ◽

R. Laxer ◽

P. Babyn ◽

E. Murphy

Keyword(s):

Compartment Syndrome ◽

Favorable Outcome ◽

Anterior Compartment ◽

Peroneal Neuropathy

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Unrecognized Anterior Compartment Syndrome Following Ankle Fracture Surgery

Journal of the American Podiatric Medical Association ◽

10.7547/0990438 ◽

2009 ◽

Vol 99 (5) ◽

pp. 438-442 ◽

Cited By ~ 2

Author(s):

Aksel Seyahi ◽

Serkan Uludag ◽

Senol Akman ◽

Mehmet Demirhan

Keyword(s):

Compartment Syndrome ◽

Ankle Fracture ◽

Open Reduction ◽

Malleolar Fracture ◽

Anterior Compartment ◽

Exercise Induced ◽

Patient’S History ◽

Fracture Surgery ◽

Compartmental Pressure ◽

Suspected Diagnosis

A 35-year-old male sustained a lateral malleolar fracture while playing football. The fracture was treated by open reduction and internal fixation with a tourniquet. The next day, the patient returned with pain and swelling of the ankle and was admitted again to the hospital with a suspected diagnosis of cellulitis. Ten hours later, the patient developed the symptoms of anterior compartment syndrome. Emergency open fasciotomy of the anterior compartment was performed. The retrospective analysis of the patient’s history was suggestive of a predisposition to an exercise-induced compartment syndrome. We think that exertional increase of the compartmental pressure before the injury and the tourniquet used during surgery contributed together to the development of compartment syndrome. Physicians should be vigilant in identifying the features of compartment syndrome when managing patients injured during a sporting activity. (J Am Podiatr Med Assoc 99(5): 438–442, 2009)

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Abstract 182: Time is Brain on the Collateral Clock! Collaterals and Reperfusion Determine Tissue Injury

Stroke ◽

10.1161/str.46.suppl_1.182 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

David S Liebeskind ◽

Dezhi Liu ◽

Nerses Sanossian ◽

Sunil A Sheth ◽

Conrad Liang ◽

...

Keyword(s):

Linear Models ◽

Tissue Injury ◽

Ischemic Injury ◽

Realistic Model ◽

Consecutive Series ◽

Imaging Data ◽

Advanced Imaging ◽

Lesion Growth ◽

Linear Fit ◽

The Relationship

Background: The pace of ischemic injury due to stroke may vary due to collaterals and degree of reperfusion. Previous linear models that estimate time is brain have not incorporated individual patient data from advanced imaging such as diffusion-weighted imaging (DWI) and angiographic assessment of collateral grade or reperfusion. We developed a realistic model of ischemic injury using detailed imaging data in a homogenous cohort of isolated M1 middle cerebral artery occlusions. Methods: Retrospective analysis of a consecutive series of isolated M1 occlusions was conducted at an expert core lab. ASITN collateral grade was assessed at baseline and extent of reperfusion after endovascular therapy (EVT) was scored with 3 distinct versions of TICI. A separate imaging expert measured DWI lesion volumes on serial MRI acquired from admission to discharge. Graphical analyses illustrated curves demarcating extent of injury over time, based on both collateral grade and extent of reperfusion. Results: 126 patients (median age 73; 88 women; median NIHSS 17; median time to 1 st DWI, 4h08min) with acute stroke due to M1 occlusion (61 proximal, 65 distal) underwent EVT during a 6-year period. Median collateral grade was 2 (range 0-4) and median TICI, 2B (range 0-3). mTICI scores were 0 (n=18), 1 (6), 2A (25), 2B (73), and 3 (4) with 24 TICI 2C scores when evaluated in detail. Total number of DWI scans was 323, with mean 2.5 per patient. Collateral grade strongly influenced pace of development of initial tissue injury (ASITN 0, 0.445 cc/min; 1, 0.276 cc/min; 2, 0.178 cc/min; 3, 0.106 cc/min; 4, 0.031 cc/min). The relationship between time and DWI lesion growth was not linear, but best fit logarithmically (R 2 = 0.985, RMSE 2.1 for log fit; R 2 = 0.757, RMSE 8.1 for linear fit). Individual lesion growth varied markedly with both collateral grade (ANOVA p<0.001) and the degree (TICI 2B/3 vs. 0,1,2A) of reperfusion (ANOVA p=0.013). Conclusions: Collateral grade and the degree of reperfusion strongly dictate the timecourse of ischemic injury in the brain after stroke onset. Advanced imaging and angiographic assessment of collaterals and reperfusion confirm a logarithmic, not linear, model that can be used to differentiate stroke patients and streamline therapeutic strategies.

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Surgical outcomes for chronic exertional compartment syndrome following improved diagnostic criteria

BMJ Military Health ◽

10.1136/jramc-2019-001171 ◽

2019 ◽

Vol 166 (E) ◽

pp. e17-e20 ◽

Cited By ~ 2

Author(s):

Christopher Simpson ◽

D Roscoe ◽

S Hughes ◽

D Hulse ◽

H Guthrie

Keyword(s):

Compartment Syndrome ◽

Diagnostic Criteria ◽

Clinical Symptoms ◽

Diagnostic Testing ◽

Rank Test ◽

Anterior Compartment ◽

Chronic Exertional Compartment Syndrome ◽

Significant Difference ◽

Exertional Compartment Syndrome ◽

The Impact

IntroductionChronic exertional compartment syndrome (CECS) presents with pain during exercise, most commonly within the anterior compartment of the lower limb. A diagnosis is classically made from a typical history and the measurement of intramuscular compartmental pressure (IMCP) testing. Improved, more specific diagnostic criteria for IMCP testing allow clinicians to now be more certain of a diagnosis of CECS. Outcomes following surgical treatment in patients diagnosed using these more robust criteria are unknown.MethodsAll patients undergoing fasciectomy for anterior compartment CECS at a single rehabilitation unit were identified between 2014 and 2017. Wilcoxen signed-rank test was used to compare military fitness grading and paired t-test was used to compare Foot and Ankle Ability Measure, FAAM Sport Specific and Exercise-Induced LimbPain-G outcome measures, presurgery and postsurgery.ResultsThere was a significant difference in fitness grading between presurgical and postsurgical intervention (Z = −2.68, p < 0.01) with 46 % of patients improving their occupational medical grading. All secondary measures of outcome, looking at clinical symptoms, also improved.ConclusionAlmost half of the patients undergoing fasciectomy, following diagnosis using more specific criteria, will have an improvement in occupational medical grading. These outcomes represent the lower end of those reported in civilian populations. This is likely a result of a combination of factors, most notably the different diagnostic criteria followed and the more stringent criteria applied to military occupational grading, compared with civilian practice. Further work is now required to evaluate the impact of differing rehabilitation regimes on postoperative patients identified through this more specific diagnostic testing.

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Compartment Syndrome of the Flexor Compartment of the Arm Secondary to Pectoralis Major Tendon Rupture

Case Reports in Orthopedics ◽

10.1155/2018/9042820 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5

Author(s):

M. A. Tranovich ◽

J. B. Stirton ◽

J. C. Maier ◽

M. B. Tanios ◽

J. E. Lea ◽

...

Keyword(s):

Compartment Syndrome ◽

Tendon Rupture ◽

Pectoralis Major ◽

Weight Lifting ◽

Rare Entity ◽

Anterior Compartment ◽

Muscle Rupture ◽

Missed Compartment Syndrome ◽

High Level

Case. Compartment syndrome following muscle rupture is a rare entity with few mentions in the literature. We present a case of pectoralis major rupture in a 38-year-old male that evolved into compartment syndrome of the anterior compartment of the arm. Rupture of the pectoralis is uncommon and most often occurs during weight lifting. Compartment syndrome secondary to this injury is extremely uncommon, with only one reported case in the pectoralis major itself and several cases of biceps compartment syndrome. Due to the potentially devastating consequences of a missed compartment syndrome, it is imperative that physicians maintain a high level of suspicion in patients with these unusual injuries presenting with severe swelling and pain.

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Dorsal Cortical Breaks in Volar Barton Distal Radius Fractures

Hand ◽

10.1177/1558944719862644 ◽

2019 ◽

pp. 155894471986264

Author(s):

Michael C. Daly ◽

Taylor A. Horst ◽

Chaitanya S. Mudgal

Keyword(s):

Distal Radius ◽

Null Hypothesis ◽

Independent Predictor ◽

Distal Radius Fractures ◽

Radius Fractures ◽

Fracture Geometry ◽

Plain Radiographs ◽

Fracture Patterns ◽

Discrete Fracture ◽

Surgical Fixation

Background: Volar Barton fractures involve the volar articular margin of the distal radius with proximal and volar subluxation of the carpus. Although traditionally conceptualized as partial articular, some volar Barton fractures are complete articular injuries due to a dorsal cortical break in the distal radial metaphysis. While dorsal cortical breaks can affect surgical strategy, they may be difficult to identify on plain radiographs and their epidemiology remains poorly characterized. Some authors have hypothesized an association with osteoporosis; however, this hypothesis remains untested. To better characterize volar Barton fractures, we analyzed fracture geometry on pre-operative computed tomography (CT) scans to: (1) determine the frequency of a dorsal cortical break; and (2) test the null hypothesis that a dorsal cortical break is not associated with age or gender. Methods: We retrospectively reviewed adults with a volar Barton distal radius fracture and an available pre-operative CT who underwent surgical fixation. Using multivariable logistic regression, we assessed whether age or gender was an independent predictor of a dorsal cortical break. Results: Forty patients (mean age 52 years, 57% female) were identified. Including the shaft as a fragment, 32 (80%) had 3 or more discrete fracture fragments. Thirty patients (75%) had a dorsal cortical break. Dorsal cortical breaks were not associated with either age or gender ( P > 0.05). Conclusions: Most (75%) patients with volar Barton distal radius fractures had a dorsal cortical break. Dorsal cortical breaks were not statistically associated with age or gender, suggesting these fracture patterns may not be associated with osteoporosis as previously hypothesized.

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