Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: A randomized prospective study

Objective: To compare anterior and deep posterior compartment pressures during reamed and unreamed intramedullary nailing of displaced, closed tibial shaft fractures. Design: Randomized prospective study. Setting: University Hospital/Level I trauma center. Patients: Forty-eight adults with forty-nine fractures treated with intramedullary nailing within three days of injury. Intervention: After intraoperative placement of compartment pressure monitors, the tibia fractures were treated by either unreamed intramedullary nailing or reamed intramedullary nailing. A fracture table and skeletal traction were not used in any of these procedures. Main Outcome Measurements: Compartment pressures and ΔP ([diastolic blood pressure] - [compartment pressure]) were measured immediately preoperatively, intraoperatively, and for twenty-four hours postoperatively. Results: Compartment syndrome did not occur in any patient. Peak average pressures were obtained during reaming in the reamed group (30.0 millimeters of mercury anterior compartment, 34.7 millimeters of mercury deep posterior compartment) and during nail insertion in the unreamed group (33.9 millimeters of mercury anterior compartment, 35.2 millimeters of mercury deep posterior compartment). The average pressures quickly returned to less than thirty millimeters of mercury and remained there for the duration of the study. The deep posterior compartment pressures were lower in the reamed group than in the unreamed group at ten, twelve, fourteen, sixteen, eighteen, twenty, twenty-two, and twenty-four hours postoperatively (p < 0.05 at each of these times. A statistically significant difference between anterior compartment pressures could not be shown with the numbers available. The ΔP values were greater than thirty millimeters of mercury at all times after nail insertion in both the reamed and unreamed groups. Conclusion: These data support acute (within three days of injury) reamed intramedullary nailing of closed, displaced tibial shaft fractures without the use of a fracture table.