Compartment syndrome following use of tissue plasminogen activator for frostbite in the setting of concomitant diaphyseal tibia fracture

BACKGROUND: Tissue plasminogen activator (tPA) is a thrombolytic agent increasingly being employed for the treatment of acute frostbite. Although tPA has been shown with success to increase digit salvage rates, data on potential complications, including risk of hemorrhage, is limited. As a result, acute trauma is considered a contraindication to use in many institution-based protocols. Currently, there is a paucity in the literature regarding use of tPA for frostbite in patients with concomitant extremity fractures. CASE PRESENTATION: We report the case of a 36-year-old male treated with tPA for frostbite to digits of his bilateral hands in the setting of a concomitant diaphyseal tibia fracture. He subsequently developed acute compartment syndrome in his lower extremity. This was followed by emergent fasciotomy and staged fracture fixation with serial wound debridement and subsequent closure. Despite this complication, the patient went on to early radiographic and clinical union of his tibia fracture. His frostbite wounds healed without functional deficits. CONCLUSIONS: In patients with severe frostbite injury with digital perfusion defects, tPA for thrombolysis may be indicated. Use of thrombolytics for frostbite in trauma patients or those with concomitant extremity fractures requires a multidisciplinary discussion regarding potential risks. Contingency planning is essential to ensure that potential bleeding complications, including development of compartment syndrome, are diagnosed and treated early. Given the paucity in the current literature regarding use of thrombolytics in trauma patients, further study is warranted to inform the surgical community on instances in which the benefits of tPA administration may outweigh the risks. LEVEL OF EVIDENCE: Case report; Level V.