Compartment syndrome

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Compartment syndrome

• Mr C Charalambides MD, FRCS(Trauma and Ortho)
• Consultant Orthopaedic Surgeon
• Whittington Hospital London

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Acute compartment syndrome

• The result of elevated pressure of tissue fluid
  within a close space
• After injury, bleeding into closed spaces
  elevates the local pressure

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• Inelastic osseofascial structures
• As pressure increases, capillary perfusion drops
  below what is required to maintain tissue
  viability
• Will eventually cause vascular occlusion and
  myoneural ischemia
• If continues, irreparable damage occurs with
  myoneural necrosis and fibrosis

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Compartments of the foot

• Medial, central, lateral, interosseous, deep
  central

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Cause of syndrome

• Fractures
• Open fractures
• Dislocations
• Crushing injuries
• Paediatric injuries

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Diagnosis

• History
• Signs and symptoms
• Clinical suspicion
• Measurement of raised intercompartmental pressures

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Symptoms signs

• Pain out of proportion
• exacerbated by passive dorsiflexion of the toes
  that stretches the intrinsic muscles
• Decreased sensation
• loss of two point discrimination
• Absent pulses

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Evaluation

• All dressings and plaster should be removed
• High elevation
• Frequent checks - progressive syndrome
• Measurement of compartmental pressure

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Pressure monitoring

• Stryker (Digital hand-held monitor)
  No18 needle
• Arterial line connected to a monitor

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Pressure monitoring

• Compartment pressure lt 30mmHg
• Diastolic Blood pressure - compartmental pressure
  gt 30mmHg

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Treatment

• Surgical decompression
• fasciotomies
• dorsal incisions over 2nd and 4th MTs
• medial incision
• NO NEED FOR USE OF TOURNIQUET
• ? Stabilization - Internal or external fixation
• Incisions are left open
• No debridement of muscles

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Rigid skeletal stability

• Soft tissue healing
• Decreases pain
• Rapid mobilization of joints
• Decreases infection possibility
• Avoidance of fracture disease

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• Second and third debridements may be needed
• Primary closure or split-thickness grafts
• tension will lead to skin necrosis

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Chronic compartment syndrome

• The consequence of untreated acute compartment
  syndrome

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Presentation

• Profound motor and sensory disturbances
• Chronic pain
• Stiffness
• Contractures
• Intrinsic atrophies
• Fixed clawing of toes
• Disuse atrophy
• Osteopenia

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Result

• Dysfunctional and painful extremity

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Muscle imbalance

• Atrophy of intrinsic muscles(interossei and
  lumbricales)
• Imbalance between intrinsic and extrinsic flexors
• Hyperextension of MTPJs
• Fixed deformities
• Excess pressure on bony prominences

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Type of deformities

• Claw toes
• Toes are hyperflexed and stiff
• Combination with deep compartment(Tib. Post, FHL,
  FDL)-equinovarus deformity

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Treatment goal

• Maximize function and relieve pain

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Treatment

• Splinting
• Joint mobilization
• Pain management
• Excision or lengthening of musculotendinous units
• Arthrodesis and osteotomy
• Neurolysis
• Correction of toe deformities

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Best to prevent than to treat
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Chronic leg pain in athletes

• Common complain
• Proper evaluation required
• Understanding of anatomy and biomechanics

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Differential Diagnosis

• Chronic compartment syndrome (33)
• Stress fracture (25)
• Medial tibial stress syndrome (13) Shin
  splints-periostitis
• Gastrosoleous complex strains (14)
• Nerve entrapment syndromes (10)
• Venous disease (4)
• Arterial occlusion
• Fascial herniations
• Tendinopathy

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Diagnosis

• Detailed history
• Clinical examination
• Diagnostic tests

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Exercise induced compartment syndrome

• Elevated compartmental pressure- ischemia of
  muscles and nerves
• Muscle contracture - increased muscle bulk
• Arterial flow normal
• Venous and lymphatic compromise

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Clinical features

• Pain after exercise, certain distance, duration
  of exercise
• Pain is acute -resolves after rest
• Cramping and sensation of fullness
• Numbness, tingling, burning sensation
• Most often affects the anterior and deep
  posterior compartments
• Two compartments can be affected simultaneously

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Clinical evaluation

• At rest - tenderness from associated periostitis
• After exercise on the treadmill
• muscle herniations, neurological symptoms

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Radiologic evaluation

• X-ray - exclude stress fracture or tumor
• Isotope bone scan - periostitis, stress fracture
• MRI

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Pressure measurements

• Resting
• Post exercise measurements

Mandatory Appropriate clinical findings
Secondary (at least one) Compartment pressure 15
mm Hg pre exercise Compartment pressure 30 mm Hg
at 1 min post exercise Compartment pressure 15
mm Hg at 5-10 min post exercise
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Non operative treatment

• ? Decrease the intensity of activities
• Cycling - no increase in pressure
• Rest. Ice, NSAIDs, insoles, orthoses
• Definitive treatment - fasciotomy

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Operative treatment

• Fasciotomies

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Results

• 80-95 excellent results
• Decrease in muscle strength

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Medial tibial stress syndrome

• Stress reaction of fascia, periosteum, or bone
  along the posteromedial aspect of tibia (shin
  splints - periostitis)

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Clinical presentation

• Pain that gets worse with exercise
• Tenderness along the tibia

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Diagnosis

• Local anaesthetic injection
• Bone scan - diffuse linear uptake

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Treatment

• Non operative
• Rest, Stretching, local steroid injection,
  Aircast boot, NSAIDs
• Operative
• fasciotomy

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Stress fracture

• Abnormal repetitive loads on the bone that cause
  an imbalance of bony resorption over formation

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Clinical features

• Change in the recent workload
• increase mileage, different shoes, altered
  terrain, change of speed
• Localized pain and tenderness
• Swelling, erythema

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Diagnosis

• X-Ray - periosteal reaction
• Isotope bone scan

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Treatment

• Non Operative
• Rest, swimming, pool running, cycling
• Operative
• Bone graft and internal fixation for non-unions
• Percutaneous drilling
• Intramedullary nailing

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Thank you