Compartment Syndrome

1. Compartment Syndrome 2LT Larson 2LT Loomis 1LT Moravec

2. AGENDA • Introduction/Purpose • Involved Anatomy • Etiology • Clinical Presentation and Dx • Treatment/Intervention • Conclusion

3. 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

4. Types of CS • Acute Compartment Syndrome • Exertional Compartment Syndrome • Acute-one time episode • Chronic- with activity

5. 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

6. Anterior Lateral COMPARTMENTS Deep Posterior Posterior

7. Etiology • Acute CS: • 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 protein-bound ions

8. Etiology • Exertional CS: • Overexertion- Associated with repetitive axial loading (runners and competitive skaters) • Muscle volume can increase up to 20% due to fiber swelling and blood filling from vigorous exercise

9. Etiology • Chronic ECS (most commonly in Deep Compartment): No anatomical predisposition has been proven • Excessive compensatory pronation of the subtalor joint implicated • During gait this would increase activity of deep posterior compartment muscles • Usually bilateral involvement (50%-70%); one extremity usually more symptomatic

10. 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

11. CLINICAL PRESENTATION • Leg pain described as a dull ache (localized or diffuse) that begins at a predictable time during exercise • May also have: • Footdrop • Giving away of the ankle • Paraesthesias in the foot • Taut, shiny, warm skin that is TTP

12. CLINICAL PRESENTATION • Post-exercise • 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

13. Differential Diagnosis • Rule out stress fractures or periostitis • Radiographs, bone-scan, bony tenderness • Medial tibial stress syndrome • 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

14. Clinical Diagnosis • Intracompartmental pressure recordings (Taken pre/post exercise w/ slit catheter under local anesthesia) Pedowitz et al.

15. Treating ECS • Conservative at first • Cross training with low impact activities (swimming, bicycling) • Rest, Ice, Elevation No Compression • NSAIDS • Stretching • Address biomechanical problems • Gradual return to activity

16. Treatment Options • If symptoms persist with activity for > 3 to 6 months • A: Stop prevocational activities • B: Have Surgery: Fasciotomy of all involved compartments

18. 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 release-as it is harder to get to • Management of fasciotomy wounds is controversial

20. 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

21. 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

22. Conclusion • Exercise induced ECS is often miss-diagnosed. • 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.

23. QUESTIONS?

24. 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.