Chronic exertional compartment syndrome of the leg

Chronic exertional compartment syndrome (CECS) is an underdiagnosed cause of chronic exertional leg pain. The syndrome most commonly occurs in young adult recreational runners, elite athletes, and military recruits. CECS is caused by increased intracompartmental pressure within a fascial space; however, the mechanism of why pain occurs is unknown. Symptoms are classically pain in the affected compartment at the same time, distance, or intensity of exercise. CECS is a clinical diagnosis; however, it is confirmed by intracompartmental pressure testing. Fasciotomy is the treatment of choice for athletes who would like to maintain the same level of activity. Athletes who have a release of the anterior and lateral compartments have a high success rate.     

Exertional compartment syndrome]

OBJECTIVES: To review the literature on chronic exertional compartment syndrome. METHODS: We searched the Medline database with use of the keys words compartment syndrome, exertional, chronic, pressure, and fasciotomy. RESULTS: Exertional compartment syndrome is characterized by pain on exertion, which recedes at rest, and by excessive increase in compartment intramuscular pressure. Intramuscular pressure measurement is the reference diagnostic tool, but it has not been standardized or evaluated. Pressure observed during the first 5 min after exertion stops is more often used in diagnosis. The first studies of noninvasive investigations (magnetic resonance imaging, thallium single-photon emission tomographic imaging, near infrared spectroscopy) revealed their inadequate diagnostic value. The pathophysiological features of exertional compartment syndrome remain unclear: increased muscle bulk, fascia thickness and stiffness, stimulation of fascial sensory stretch-receptors, poor venous return, micromuscular injuries, and small clinical myopathic abnormalities. Treatment includes decreased sport activity or fasciotomy with partial fasciectomy. Several authors have used endoscopically assisted fasciotomy, which retrospective studies have shown to be successful. Long-term outcome studies could investigate the persistence of exertional minor pain and recurrence of the compartment syndrome with this treatment. CONCLUSION: Further studies are required to understand the physiopathology, standardize the intramuscular pressure test and evaluate the pressure threshold values, evaluate noninvasive investigations and specify the long-term outcome of fasciotomy.     

The exertional compartment syndrome: A review of the literature

An author reviews the literature concerning exertional compartment syndrome that may occur in sports and exercise in an acute and a chronic form. The chronic (exertional) form is more common than the acute syndrome and most of the cases located in the anterior and lateral compartments of the lower leg. This review article describes the clinical features of the syndrome and discuss some of the uncertainties regarding anatomy, patophysiology, diagnostics and management. An author states that the only logical treatment of the compartment syndrome is surgical fasciotomy, a minor, but succesfull surgery with low complications rate.     

Well‐leg compartment syndrome after laparoscopic low anterior resection for lower rectal cancer in the lithotomy position: A case report

A 64‐year‐old man underwent laparoscopic low anterior resection for lower rectal cancer. Because he was overweight (BMI, 28.1 kg/m²) with rich visceral fat and a narrow pelvic cavity, the operation was technically difficult and the operation time was 686 min. Postoperatively, the patient immediately complained of pain and swelling of the left lower limb. Laboratory examination showed that serum creatinine kinase was markedly increased and urine myoglobin was positive on postoperative day 1. He was diagnosed with well‐leg compartment syndrome and was transported to the trauma and critical care center for emergency fasciotomy. After initial treatment, he was transferred to our hospital on postoperative day 7. He completely recovered after 2 months. Although well‐leg compartment syndrome is rare, it is necessary to consider it as a potential complication when performing a long colorectal cancer surgery with the patient in the lithotomy position, particularly when laparoscopic surgery is planned.     

Is there a role for fasciotomy in Crotalinae envenomations in North America?

Context. The local effects of Crotalinae envenomation can cause significant tissue destruction, pain, paresthesias, and deformity of the limb, which mimic findings of compartment syndrome, despite rare subfascial penetration of the fangs. Complicating this are the various techniques and ideas about what determines compartment syndrome combined with the fact that elevated intracompartmental pressures have been documented after Crotalinae envenomation, without clear evidence of compartment syndrome or tissue hypoperfusion. Objective. The purpose of this review is to evaluate the North American literature to provide an evidenced-based conclusion about the indications for fasciotomy in Crotalinae envenomations. Methods. The search was conducted with studies published only in the English language. The search included all human and animal publications, regardless of the format of study. The Cochrane Central Register, MEDLINE/ Pub Med, Scopus, and Biological Science databases were searched. Citations from all the articles were also cross-referenced if they were pertinent to the review. Major toxicology and emergency medicine and surgical textbooks were also referenced. Abstracts from the North American Congress of Clinical Toxicology, Poisonidex^®, and personal articles were also scanned to complete the process, resulting in a total of 640 sources. Papers were excluded if they were duplicates, non-North American, involved excisional therapy, or did not discuss fasciotomy. This left 99 publications applicable to our study. Findings. No randomized controlled trials, 8 animal experiments, 1 human prospective observational study, 24 retrospective reviews, 32 review articles, 10 case reports, 15 textbooks references, 2 abstracts, and 7 editorials were included in the analysis. Controlled animal experiments show that crotaline Fab antivenin reduces intracompartmental pressure and increases tissue perfusion, while fasciotomy either has no beneficial effect or worsens myonecrosis. The case reports and opinions supporting fasciotomy come from the surgical literature and precede the modern crotaline Fab antivenin. Conclusion. The current evidence does not support the use of fasciotomy or dermotomy following Crotalinae envenomation with elevated intracompartmental pressures. At present, early and adequate administration of crotaline Fab antivenin is the treatment of choice. Fasciotomy cannot be recommended until further well-designed investigations are completed.     

Foot Compartment Syndrome: A Rare Presentation to the Emergency Department

Background

Compartment syndrome of the foot is a rare but life- and limb-threatening condition that is often difficult to diagnose. The common signs and symptoms of compartment syndrome are pain out of proportion to the injury, pain with passive stretch of the compartment, paresis, paresthesias, and often, intact pulses. Foot compartment syndrome is often caused by traumatic injuries, and the clinical presentation may be confusing in this setting. The foot contains nine compartments, which should all be assessed for elevated compartment pressures. Definitive management is fasciotomy. Prompt recognition, diagnosis, and treatment are essential to prevent devastating complications.

Objectives

This article discusses the key components of presentation, diagnosis, and management of foot compartment syndrome.

Case Report

A patient presented to the Emergency Department (ED) with a crush injury of his foot. He had significant swelling and pain in his foot, but no fractures were identified on X-ray study. Given the severity of his injury and pain, foot compartment pressures were measured to accurately diagnose foot compartment syndrome. The patient underwent fasciotomies of the foot within 3 h of presentation to the ED and suffered no sequelae at the time of follow-up in clinic.

Conclusion

Foot compartment syndrome is a surgical emergency that can be difficult to diagnose. Early diagnosis with compartment pressure measurements is crucial, as definitive management with fasciotomies can prevent long-term sequelae.     

半量甘露醇治疗早期骨筋膜室综合征

目的：观察半量甘露醇治疗早期骨筋膜室综合征的临床效果。方法：回顾性分析92例四肢创伤后诊断为早期骨筋膜室综合征患者应用半量甘露醇静脉滴注治疗后症状和体征的变化。结果：88例患者用药2—8h后疼痛明显缓解，肿胀肢体周径减小，皮肤紧张度下降，局部触压痛减轻；4例最终行骨筋膜室切开减压术。全部患者均无急性肾功能衰竭(ARF)发生。结论：半量甘露醇可明显改善早期骨筋膜室综合征表现，可作为常规预防性用药，但对用药后无缓解或暂时性缓解又进行性加重的患者应积极早期手术，其疗效可作为选择手术时机的一个参考指标。     

Evaluation and Management of Acute Compartment Syndrome in the Emergency Department

Background

Acute compartment syndrome (ACS) is a time-sensitive surgical emergency caused by increased pressure within a closed compartment. ACS can lead to significant morbidity and mortality if it is not rapidly identified and treated.

Acute compartment syndrome of the dorsal forearm following noncontact injury

Acute compartment syndrome is a limb-threatening condition in which early diagnosis and surgical consultation for fasciotomy are required to preserve functional outcome. The diagnosis is typically considered in patients with traumatic mechanisms of injury such as a direct blow and crush to the compartment, particularly when there is a fracture in the same compartment. We report the case of a patient with acute compartment syndrome of the dorsal forearm that occurred as a result of an atypical noncontact traumatic mechanism. Establishing the diagnosis of compartment syndrome was complicated in this patient, as some of the signs and symptoms of acute compartment syndrome could have been attributed to the presence of a coexisting rupture of the extensor digitorum muscle. This report serves to remind emergency physicians that, although rare, acute compartment syndrome can result from exertional and noncontact traumatic mechanisms.     

‘The needle and the damage done’: Intra‐arterial temazepam

Intra‐arterial temazepam injection by intravenous drug abusers may be associated with vascular and metabolic complications. Patients generally present with severe pain, mottling and swelling of the limb. This can progress to tissue loss. The pathophysiology is not clearly defined, but may include direct vascular injury, as well as rhabdomyolysis. This is illustrated by two cases that presented to The Geelong and St Vincent's Hospitals, Victoria, Australia, resulting in compartment syndromes, limb ischaemia and rhabdomyolysis. Treatment consists of reducing intracompartmental pressure, attempts to re‐establish blood flow by either pharmacological or surgical methods and supportive care. Compartment syndromes and ischaemia may take hours to develop, so that prolonged observation is indicated. Evidence of raised intracompartmental pressure or limb ischaemia warrants early and aggressive intervention in order to prevent or minimize the limb‐ and life‐threatening consequences of intra‐arterial injection of temazepam.     

Enoxaparin-induced bleeding resulting in compartment syndrome of the thigh: a case report

Background: Enoxaparin-related bleeding has usually been described as excess minor bleeding. Objectives: To describe a case of major bleeding with a compartment syndrome secondary to enoxaparin. The utility of bedside emergency department ultrasonography as a diagnostic tool is evident. Case Report: A 62-year-old patient presented with swelling and pain in the left thigh with no history of trauma. Examination revealed a swollen extremity with a tense muscle compartment. A bedside ultrasound by the emergency physician was performed, showing a large pocket of fluid accumulation. Upon aspiration, the fluid was found to be blood. Computed tomography imaging was performed, which revealed a large hematoma, with active bleeding. Subsequent angiography showed several extravasations from the profunda artery. The patient was then taken for embolization of the bleeding, and then an anterolateral fasciotomy. The patient had an increased partial thromboplastin time, and final diagnosis was compartment syndrome due to spontaneous bleeding from enoxaparin. Conclusions: Enoxaparin can spontaneously cause serious bleeding with associated compartment syndrome.     

Case report: acute forearm compartment syndrome due to sudden, forceful supination of the hand

Acute compartment syndrome is a limb-threatening condition if not recognized and treated promptly. Appropriate management includes early fasciotomy, which often results in better functional outcomes. Although there are many causes of compartment syndrome, the common findings are significant pain, swelling, and limited range of motion. Diagnosis is usually based on physical findings in the setting of a compelling history. Before surgical intervention, the diagnosis is usually confirmed by measuring elevated compartment pressures. The patient described in this case report developed acute compartment syndrome of the forearm after his hand became trapped in machinery that applied sudden supination to the hand, and avulsed the distal portion of the left index finger. There was no direct trauma to the forearm. In this case, acute compartment syndrome was likely due to a combination of contained hemorrhage into the muscle sheath, closed muscle strain causing edema, and possibly axial traction applied to the tendons of the index finger. Acute compartment syndrome should be considered in the differential diagnosis for any patient complaining of severe pain in an extremity, even in the absence of commonly recognized mechanisms of injury.     

Hypokalemia, hypophosphatemia, and compartment syndrome of the leg after downhill skiing on moguls

Any process that increases intracompartmental pressure may precipitate compartment syndrome. We report the case of a patient with hypokalemia and hypophosphatemia who presented with compartment syndrome of the legs after a day of downhill skiing on moguls. The presentation is followed by a review of the pathophysiology, etiology, clinical presentation, and management of compartment syndrome, as well as the relationship between hypokalemia, hypophosphatemia, and the development of muscle injury.     

A Case of Delayed Presentation of Thigh Compartment Syndrome

Background

Thigh compartment syndrome is a rare and devastating process. It generally occurs within hours to days of a traumatic event, although cases have been reported nearly 2 weeks after the initial event.

Objectives

To evaluate the literature describing the timing between inciting event and presentation of thigh compartment syndromes, with a focus on delayed presentations of this rare condition. To describe the unique properties of thigh compartments, and finally, to review the anatomy and techniques needed to measure the compartment pressures of the thigh.

Case Report

A case of a 54-year-old man is presented. He sustained trauma to his thigh 17 days prior to presenting to our ED with severe, sudden-onset pain in his right thigh. Compartment pressures were measured and confirmed the diagnosis of compartment syndrome caused by two large intramuscular hematomas. No other contributing events were identified.

Conclusions

Compartment syndrome in the thigh should be considered in patients with a concerning examination and a history of recent trauma. This particular case represents the longest reported time between injury and development of a thigh compartment syndrome.     

Lower extremity compartment syndrome. When to suspect acute or chronic pressure buildup

Acute compartment syndrome is a surgical emergency. A high index of suspicion is needed in cases of severe contusion, especially if patient complaints seem to outweigh physical findings. Acute surgical fasciotomy is an effective treatment and should be carried out expeditiously if compartment pressures are elevated over 70 mm Hg in order to avoid complications such as chronic disability due to contractures or rhabdomyolysis with acute renal failure. Chronic exertional compartment syndrome most often occurs in the anterior or the lateral compartment. Patients have only exercise-related symptoms and recover quickly after resting from the inciting activity. Diagnosis is difficult, but the anterior compartment pressure may be checked fairly readily with a handheld pressure catheter. Deep posterior compartment problems are harder to check because of the difficulty in reaching this area. Thallium stress testing appears promising for diagnosing both anterior and posterior problems and may augment, or even replace, the catheter measurement in the deep posterior and perhaps even the anterior compartment. Thallium stress testing is noninvasive and may be a more physiologic measurement. Fasciotomy may be indicated if conservative treatment lacks efficacy. For unknown reasons, the deep posterior compartment does not respond as quickly, or as well, to fasciotomy as the anterior compartment.     

Acute compartment syndrome: obtaining diagnosis,providing treatment,and minimizing medicolegal risk

Acute compartment syndrome (ACS) is a surgical emergency. Diagnosis depends on a high clinical suspicion and an understanding of risk factors, pathophysiology and subtle physical exam findings. The typical high risk scenario for ACS is a male patient younger than 35 years of age, involved in a high energy sport or roadway collision, resulting in a tibial shaft fracture. He will go on to develop acute compartment syndrome of the leg in less than 10 hours and require emergent fasciotomy. Diagnosis of ACS in this patient is primarily a clinical one but can be confirmed with invasive intracompartmental pressure monitoring or non-invasive near infrared spectroscopy (NIRS). Delaying the diagnosis will likely result in some degree of permanent disability and places the surgeon at high risk for litigation. This article reviews the salient features of acute compartment syndrome that should be understood by all orthopaedic residents and surgeons.     

Acute compartment syndrome following a minor athletic injury

An athletic young male presented with right calf pain following a twisting injury during a soccer game. Other than apparently severe calf pain, no symptoms or signs of compartment syndrome were noted. The patient later returned with lateral and anterior compartment syndrome, and suffered partial loss of peroneal nerve and muscle function despite fasciotomy. Although rare, acute compartment syndrome resulting from seemingly minor injury or exertion has been reported. Pain out of proportion to the apparent injury and a history of chronic leg pain with exertion may be helpful in identifying these patients prior to development of more obvious signs and symptoms. The diagnosis of acute compartment syndrome may be confirmed by compartmental pressure measurement. Prompt intervention is indicated once the diagnosis is established.     

21例胫腓骨骨折合并动脉损伤患者的分析

目的探讨胫腓骨骨折合并动脉损伤的临床特点和诊治方法。方法回顾性调查在605例2001年10月至2005年6月在本院就诊的胫腓骨骨折患者中,伴有月国动脉、胫前和(或)胫后动脉损伤的21例患者资料。结果月国动脉损伤14例(66.7%),其中4例伴月国静脉损伤;胫前动脉4例(19.0%),其中2例伴胫前静脉损伤;胫前胫后动脉3例(14.3%),其中伴胫前、胫后静脉损伤各1例。血管吻合术11例,取栓加血管修补术5例,自体大隐静脉移植1例,人工血管移植3例,单纯胫前动脉残端结扎止血1例。最终8例(38.1%)患者保肢成功,13例行二期截肢(趾)手术。截肢(趾)组13例患者均于骨折固定术后48h内发现患肢足背动脉搏动减弱或消失,皮肤色泽改变,与保肢组相比差异具有统计学意义(P<0.01)。5例患者行骨折固定前发现伴有骨筋膜室综合征于术中减压,另有2例术后预防性切开减压,其中3例最终保留患肢。结论对于胫腓骨骨折,特别是胫骨平台骨折患者,需警惕伴行动脉损伤。早期发现、早期诊断合并重要动脉损伤的胫腓骨骨折,及时重建血管并处理骨筋膜室综合征,对患肢预后有重要意义。