Tibial shaft fractures account for approximately 2% of all adult fractures [1, 2]. A potentially devastating complication, acute compartment syndrome (ACS) is reported in 1.2–11.4% of tibial shaft fractures [3,4,5,6,7,8]. ACS is a destructive end-point condition where the pressure in muscle compartments [increased intracompartmental pressure (ICP)] might cause muscular and nervous breakdown with very poor longterm outcome. The risk factors for ACS include male gender, open tibial fracture, high energy trauma, knee dislocation, age below 55 years, vascular injury in the same leg, Injury Severity Score (ISS) > 16, and polytrauma [3, 5, 7,8,9,10,11].

Limb swelling, caused by the injury itself, can lead to increased ICP in all four muscle compartments of the lower leg. Also, the operative treatment for the fracture can further intensify the ICP and, therefore, lead up to the development of severe ACS. The devastating cascade from increased ICP to the development of ACS is caused by decreased blood flow within the compartments, progressive ischemia and hypoxia, and eventually, if left untreated, muscle and nervous necrosis [5, 11].

The symptoms of ACS in the lower limb include severe pain, nerve palsy, paresthesia and paresis distal to the knee, and lack of arterial supply [5, 11]. The diagnosis of ACS is primarily based on the clinical estimation of the symptoms, but the measurement of ICP can be utilized as a support for the decision making [11, 12]. The gold standard for the treatment of ACS is immediate fasciotomies of all four muscle compartments, commonly performed during the initial stabilization of the fracture. Fasciotomies are usually carried out through the double incision technique, although a single incision technique can also be used [5, 13,14,15]. Skin closure after fasciotomies can be done directly or by using split thickness skin grafts [16, 17].

ACS and fasciotomies after tibial shaft fracture are associated with a higher risk for complications and poor functional outcomes [3, 6, 10, 18]. Fasciotomies can impair the fracture healing process, leading to longer healing times and increased rates of delayed union or nonunion (55% versus 17.8%) [18]. In cases of delayed ACS diagnosis, it has been reported that 10 out of 11 patients have ongoing problems, such as infections, sensory deficits, muscle weakness, and contractures [3, 10].

Currently, reamed intramedullary tibial nailing (IMN) is the standard method for stabilizing tibial shaft fractures [18]. Commonly used and widely reported operative techniques are performed through the infrapatellar (IP) or suprapatellar (SP) approaches [20,21,22,23]. Also, lateral or medial parapatellar approaches can be used. The incidence of tibial fracture nailing, according to the Finnish Care Register for Health Care, during the last 18 years has been approximately 10/100,000 persons per year [24].

Infrapatellar IMN is performed in supine position, with the knee in deep hyperflexion to accommodate the proper entry for the tibial nail. Reduction of the fracture is achieved with calcaneal traction, where a K-wire through the calcaneal bone is attached to the traction table. Instead, suprapatellar IMN is performed with the knee in full extension or only in 20–30° flexion. Fracture reduction is attained with straight pull of the limb by assisting operator. This traction method might be considered gentler when the intensity and duration of traction can be modified during the operation.

According to recent studies and a meta-analysis, SP IMN has multiple advantages compared with IP IMN [25]. These advantages include shorter fluoroscopy time, less anterior knee pain, better or similar recovery of knee function, and more accurate fracture reduction compared with the IP technique [16, 19, 25,26,27,28,29,30]. However, surgical time, blood loss, knee infection rate, nonunion rate, and closed reduction rate do not seem to differ significantly [19, 25,26,27,28,29,30,31].

There is some evidence that calcaneal traction for the IP IMN technique can lead to increased ICP in tibial fractures during intramedullary nailing [14, 32]. The injury itself and the use of traction might together increase the risk for ACS [14]. It has also been suggested that the deep flexion position of the leg in the IP technique might cause increased ICP by impairing venous drainage. Furthermore, the venous outflow from the injured limb might also be compromised by popliteal support, which is often mandatory to gain proper traction when using IP nailing technique. Traction, flexed position of the knee and popliteal support used in the IP IMN technique might be considered the main perioperative risk factors for the development of ACS.

A few studies have reported the rates of fasciotomies due to ACS after tibial fractures. Lindvall et al. reported of series of 22 patients treated with IP IMN with no fasciotomy [33]. Cheng et al. had 152 patients treated with SP IMN, of which one patient developed ACS and needed fasciotomies postoperatively [34]. In a multicenter case series of 180 patients treated with IP IMN, the risk of ACS was 3.8% [35]. To our knowledge, there is no previous studies that have compared the rate of fasciotomies between the SP and IP techniques.

The primary aim of this study is to compare the rate of peri- and postoperative fasciotomies for ACS using the SP IMN and IP IMN techniques in the treatment of tibial shaft fractures.