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Case 4

Case 4. Table 24 Laura Butz, Natalie King Chris Minning, Fred Roepcke. 15 y/o female complaining of pain in anterior left leg History Decided to go out for school’s cross-country team A couple days after workouts she started complaining of pain in anterior left leg

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Case 4

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  1. Case 4 Table 24 Laura Butz, Natalie King Chris Minning, Fred Roepcke

  2. 15 y/o female complaining of pain in anterior left leg • History • Decided to go out for school’s cross-country team • A couple days after workouts she started complaining of pain in anterior left leg • Coach told her it was probably “shin splints” and that she’d probably be fine if she kept running • She kept running and pain worsened • Pain got worse throughout the night and she went to the ER

  3. Vital Signs • All vitals are normal

  4. Physical Exam • Musculoskeletal • Left leg red and swollen • Anterior aspect of leg sensitive to palpation and felt harder and warmer than other parts of leg • Dorsiflexion of foot and toes severely limited • Dorsalispedis pulse was weak and sensory loss was noted between 1st and 2nd • Neurological • Normal

  5. Dorsiflexion vs. Plantarflexion

  6. Questions • What muscles dorsiflex the foot? • Tibialis anterior • Extensor Hallicus Longus • Extensor Digitorum Longus • To which compartment do these muscles belong • Anterior compartment • What is the innervation and blood supply to this compartment • Deep fibular n. and anterior tibial a.

  7. Course of Deep Fibular N. and Anterior Tibial Artery Deep fibular n. Anterior Tibial a.

  8. Questions • What are the other two compartments of the leg? • Lateral Compartment • Posterior Compartment • Divided into Superficial and Deep Layers

  9. Lateral Compartment of Leg • What muscles make up this compartment? • Fibularis Long • Fibularis Brevis • Blood supply and innervation? • Fibular artery • Superficial fibular n. • Actions • Eversion and plantarflexion

  10. SF Posterior Compartment of Leg • What muscles make up this compartment? • Gastrocnemius • Soleus • Plantaris • Blood supply and innervation? • Posterior tibial a. • Tibial n. • Actions • Plantarflexion

  11. Deep Posterior Compartment of Leg • What muscles make up this compartment? • Popliteus • Flexor Hallicus Longus • Flexor Digitorum Longus • Tibialis Posterior • Blood supply and innervation? • Posterior tibial a. • Tibial n. • Actions • Plantarflexion and inversion

  12. Question • What do you think happened to the girl's leg in this case? • Overexertion of muscles caused them to swell – no space to expand within anterior compartment • Chronic exertional compartment syndrome (CECS) • Acute typically caused by trauma • What clues would indicate paralysis of anterior compartment muscles? • Inability to dorsiflex foot – foot drop

  13. Anterior Tibial Artery • What would explain the weak pedal pulse? • Anterior tibial artery compression • If the artery were completely closed would there still be any blood flow to the dorsum of the foot? • Yes, due to the collateral flow through the deep plantar artery

  14. Question • How does one explain the sensory loss in the girl’s foot? • Injury to the Deep fibular n. • Deep fibular n. provides sensory innervation to the adjacent sides of the 1st and 2nd metatarsal

  15. Questions • How was the deep fibular nerve compromised? • Due to the sudden increase in exercise, the muscles in the anterior compartment swelled, increasing the pressure in the anterior compartment. • This may compress the nerve

  16. Questions • What else is innervated by the Deep Fibular Nerve? • In addition to all muscles in the anterior leg compartment, the Deep Fibular nerve supplies motor innervation to the Extensor Digitorum Brevis. • We could test to see if there is motor loss to this muscle to confirm the diagnosis.

  17. Diagnosis • Objective pressure measurements are the gold standard for diagnosis • The primary characteristic distinguishing the chronic condition is pressure elevation during exercise and a slower return to resting value at the end of exercise

  18. Treatment Rest from activity that is causing the pain Once pain subsides slowly re-introduce stressful exercises Wear proper shoes for athletic activities If “shin splints” are recurring shoe inserts may correct any foot variation causing the pain

  19. Treatment • In severe cases, fasciotomy may be necessary • Cut open compartment to relieve pressure and remove necrotic muscle

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