ASSOCIATED FRACTURE

A long-standing knowledge gap in fracture care is in regard to the effect of the timing of definitive fracture fixation on infection rate, fracture healing and other outcomes in patients with fractures complicated by ACS. Four recent studies identified in this Rapid Update, all low methodological quality, examine the influence of the management of an associated fracture on the outcome of acute compartment syndrome (ACS) (Akbari, 2019, Dubina, 2022, Flagstad, 2020, Ull, 2020), in addition to one low quality study from the original CPG (Kim, 2017). Three of the five studies demonstrate decreased infection rates with internal fixation of the fracture at or before the time of fasciotomy closure (although the differences did not always reach statistical significance) (Akbari, 2019, Dubina, 2022, Flagstad, 2020). The other two papers report the infection rate to be unaffected by the timing of fixation (Kim, 2017, Ull 2020). No deep infections occurred in the series reported by Kim et al, and the infection rate was 13% in both early and delayed fixation groups in the study by Ull et al.  With respect to other outcomes, Kim et al. found no significant differences in any outcome comparing immediate internal fixation to a staged approach of immediate external fixation and delayed internal fixation in tibial fractures requiring fasciotomy. In contrast, Akbari et al also compared early internal fixation to a staged approach but found several outcomes were worse in the patients that underwent staged management. Specifically, deep infection, malunion, decreased range-of-motion of the knee and ankle, number of surgeries, and duration of hospitalization were all greater in the staged fixation group (Akbari, 2019). Ull et al compared primary (early) to secondary (delayed) internal fixation in patients with ACS complicating a lower leg fracture and found no differences in clinical outcomes but significantly shorter hospital stays and need for significantly fewer surgeries in patients receiving early internal fixation. Dubina et al sought to determine if the risk of fracture-related infection (FRI) in patients with tibial plateau fractures complicated by ACS differed based on the timing of tibial plateau fixation relative to closure of ipsilateral fasciotomy wounds. Although the overall rate of FRI was high (19.6%), Dubina et al concluded that internal fixation at the time of fasciotomy closure has the highest probability of treatment benefit. Finally, the study by Flagstad et al showed improved articular reduction of tibial plateau fractures with fixation performed before or at the same time as fasciotomy closure. These authors acknowledge a selection bias caused by the possibility that more severe fractures were treated by delayed closure and fixation due to soft tissue injury. Taken together, all five of these papers show either benefits or no difference comparing internal fixation at or before the time of fasciotomy closure to either definitive external fixation or later internal fixation, while no outcomes were better in patients treated with delayed fixation. However, in these studies the patient populations, fracture type, protocols for treatment, and other characteristics were not standardized and none of the studies were prospective randomized trials.  Although these newer papers suggest that early internal fixation can be safely performed in many patients with fractures and associated ACS with the expectation of equivalent to better outcomes than definitive external fixation or a staged approach using delayed internal fixation, this evidence is not of high enough quality to change the current consensus recommendation of the workgroup.

Posssible Harms of Implementation

While the original workgroup opinion remains that initial operative fixation (external or internal) of associated fractures should be performed in patients with ACS, the literature is still not definitive enough to make a recommendation regarding the timing of fracture fixation or the specific type of fixation. The existing evidence is likely influenced by significant selection bias. Failure to consider all patient characteristics in choosing the timing and type of fixation may lead to increased infection and other complications. The degree of soft tissue injury, fracture location, method of fixation and patient/injury factors should all be considered in determining the best comprehensive treatment plan. Patients with significant soft tissue injury, severely contaminated open fractures and complex periarticular fractures may benefit from staged or delayed internal fixation. In patients with peri- or intra-articular fractures, the potential benefit of improved fracture reduction with early internal fixation must be balanced against the risk with respect to deep infection.
 

Future Research

Prospective studies using matched study populations with similar soft tissue and fracture characteristics, definitive protocol-driven fixation type, soft-tissue management, and post-operative rehabilitation will aid in determining optimal timing of fracture fixation with associated fasciotomy. Randomized studies of patients requiring fasciotomy for ACS comparing external fixation and immediate fixation for similar fractures would be beneficial.
 

2025 UPDATE ADDITIONAL EVIDENCE

1. Akbari Aghdam, H., Sheikhbahaei, E., Hajihashemi, H., Kazemi, D., Andalib, A.. (2019). The impacts of internal versus external fixation for tibial fractures with simultaneous acute compartment syndrome. European journal of orthopaedic surgery & traumatologie, 29(1), 183-187.
2. Dubina, A. G., Morcos, G., O'Hara, N. N., Manzano, G. W., Vallier, H. A., Farooq, H., Natoli, R. M., Adams, D., Obremskey, W. T., Wilkinson, B. G., Hogue, M., Haller, J. M., Marchand, L. S., Hautala, G., Matuszewski, P. E., Pechero, G. R., Jr., Gary, J. L., Doro, C. J., Whiting, P. S., Chen, M. J., DeBaun, M. R., Gardner, M. J., Reynolds, A. W., Altman, G. T., Obey, M. R., Miller, A. N., Haase, D., Wise, B., Wallace, A., Hagen, J., O'Donnell, J., Gage, M., Johnson, N. R., Karunakar, M., Dynako, . (2022). Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients. Injury, 53(11), 3814-3819.
3. Flagstad, I., Albright, P., Pedri, T., Kleinsmith, R. M., Schmidt, A., Alley, M., Westberg, J. R., Moreno, A. F., Henry, G., Tatman, L. M., Obremskey, W. T., Tornetta, P., 3rd, Cunningham, B. P.. (2024). Early Versus Delayed Definitive Fixation Relative to Fasciotomy Closure in High-Energy Tibial Plateau Fractures with Compartment Syndrome. Journal of Orthopaedic Trauma, 08(0), 08. Ull, C., Jansen, O., Seybold, D., Konigshausen, M., Schildhauer, T. A., Gessmann, J.. (2020). Differences between primary and secondary definitive osteosynthesis for fractures of the lower leg with concomitant acute compartment syndrome. European Journal of Trauma & Emergency Surgery, 46(5), 1167-1173.
4.  Ull, C., Jansen, O., Seybold, D., Konigshausen, M., Schildhauer, T. A., Gessmann, J.. (2020). Differences between primary and secondary definitive osteosynthesis for fractures of the lower leg with concomitant acute compartment syndrome. European Journal of Trauma & Emergency Surgery, 46(5), 1167-1173.