Transcript Compartment Syndrome - Hill Country Trail Runners

Compartment Syndrome
2LT Larson
2LT Loomis
1LT Moravec
AGENDA
Introduction/Purpose
Involved Anatomy
Etiology
Clinical Presentation and Dx
Treatment/Intervention
Conclusion
INTRODUCTION
Compartment Syndrome can be a life/limb
threatening emergency
Related to acute trauma or exertion
Affects the muscle tissue, innervation, and
vascularization within a MS compartment
Has also been described in the foot, thigh,
forearm and gluteal regions
Types of CS
Acute Compartment Syndrome
Exertional Compartment Syndrome
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Acute-one time episode
Chronic- with activity
Under Pressure?
From Anatomy we all know the Crural
Fascia is VERY tight and has a limited
ability to expand
Increased compartmental pressure can
result in ischemia, neuropraxia and if
sustained, tissue NECROSIS
Etiology
Acute CS:
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Direct trauma = Fx or soft-tissue injury
More common in men (McQueen et al)
Initial injury leads to swelling within
compartment
Muscle damage theorized to increases
osmotic pressure from release of proteinbound ions
Etiology
Exertional CS:
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Overexertion- Associated with repetitive
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axial loading (runners and competitive
skaters)
Muscle volume can increase up to 20% due to
fiber swelling and blood filling from vigorous
exercise
Etiology
Chronic ECS (most commonly in Deep
No anatomical predisposition
has been proven
Excessive compensatory pronation of the
subtalor joint implicated
Compartment):

During gait this would increase activity of
deep posterior compartment muscles
Usually bilateral involvement (50%-70%);
one extremity usually more symptomatic
CLINICAL PRESENTATION
Pnt c/o severe pain
out of proportion to
injury
Pain aggravated by
passive muscle
stretch
Loss of sensation
may be useful sign
Dorsalis pedis pulse
may or may not be
affected
http://www.physsportsmed.com
CLINICAL PRESENTATION
Leg pain described as a dull ache
(localized or diffuse) that begins at a
predictable time during exercise
May also have:
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Footdrop
Giving away of the ankle
Paraesthesias in the foot
Taut, shiny, warm skin that is TTP
CLINICAL PRESENTATION
Post-exercise
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Involved compartments are swollen and tense
Increased leg girth over involved muscles
Passive stretching of involved muscles may
increase pain
Symptoms usually lessen within 30 min
Differential Diagnosis
Rule out stress fractures or periostitis
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Radiographs, bone-scan, bony tenderness
Medial tibial stress syndrome
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pain and tenderness over soleus bridge
pain with exercise which can progress to other
activities
pain increased by hyperpronation of the foot
Compression neuropathies
electromyography
Clinical Diagnosis
Intracompartmental pressure recordings
(Taken pre/post exercise w/ slit catheter under local
anesthesia)
Measurement
Pressure
Pre-exercise
1 min Post-exercise
5 min Post-exercise
> 15 mm Hg
> 30 mm Hg
> 20 mm Hg
Pedowitz et al.
Treating ECS
Conservative at first
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Cross training with low impact activities
(swimming, bicycling)
Rest, Ice, Elevation No Compression
NSAIDS
Stretching
Address biomechanical problems
Gradual return to activity
Treatment Options
If symptoms persist with activity for > 3 to
6 months

A: Stop prevocational activities
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B: Have Surgery: Fasciotomy of all involved
compartments
Surgical Outcome
Dependent upon compartment involvement
 Results of anterior and lateral releases are
superior to posterior release
 Failure of Deep posterior compartment
release largely due to insufficient releaseas it is harder to get to
 Management of fasciotomy wounds is
controversial
Outcomes of Fasciotomies in CECS
Good/Excellent
Study
Results (%)
Froneck et al. (1987)
92
Detmer et al. (1985)
90
Rorabeck et al. (1988)
88
Styf (1987)
90
Abramowitz and Schepsis (1994)
77
Criteria for Results
Pain, exercise tolerance
Pain, exercise tolerance
Pain, exercise tolerance *
Free of all symptoms
Free of all symptoms #
* All failures were deep posterior compartment
# Seven of eight failures were deep posterior
PT Intervention Post Surgery
Immediate Ice and Elevation
Crutches (TTWB) with gradual progression to
FWB (1 week)
Gait training to prevent abnormal movement
secondary to stiffness and guarding
ROM exercises to increase circulation:
 ankle dorsiflexion, plantar flexion, inversion,
eversion, alphabet exercise
 knee flexion/ extension
Rehab Progression
Gentle isokinetics
Stretching, of involved muscles
Aerobic training: Limited WB
(swimming/cycling)
4 weeks:
 progression to running and resistive
weight training as tolerated
2-3 months full return to training
Conclusion
Exercise induced ECS is often missdiagnosed.
Awareness is key due to the dangers of
untreated acute ECS.
Non-surgical interventions not shown to
help long term.
Surgery is intervention for reliably high
prognosis.
PT plays important role in Dx and post
surgical Tx.
QUESTIONS?
REFERENCES
1.
Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes.
British Journal of Surgery. 2002; 89(4): 397-412.
2.
McQueen MM, Gaston P, Court-Brown CM. Acute compartment
syndrome. Who is at risk?[comment]. Journal of Bone & Joint Surgery - British
Volume. 2000;82(2):200-203.
3.
Pearse MF, Harry L, Nanchahal J. Acute compartment syndrome of the
leg: fasciotomies must be performed early, but good surgical technique is
important. British Medical Journal. 14 September 2002 2002;Volume
325(7364):557-558.
4.
Garcia-Mata S, Hidalgo-Ovejero A, Martinez-Grande M. Chronic exertional
compartment syndrome of the legs in adolescents. Journal of Pediatric
Orthopedics. 2001;21(3):328-334.
5.
Prentice WE, Voight MI. Techniques in musculoskeletal rehabilitation. New
York: McGraw-Hill; 2001.
6.
Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg:
are clinical findings predictive of the disorder? Journal of Orthopaedic Trauma.
2002;16(8):572-577.
7.
Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome:
course after delayed fasciotomy. Journal of Trauma-Injury Infection & Critical
Care. 1996;40(3):342-344.