Treatment of compartment syndrome in children

A compartment syndrome is a symptom complex caused by elevated tissue pressure in a closed osseofascial compartment of a limb. Left unrecognized, it results in permanent damage to muscle and nerve in that compartment. The diagnosis of a compartment syndrome is contingent on the recognition of pain out of proportion with the injury as the most important early symptom. The pain is increased with passive stretching of the muscles in the involved compartment or on palpation of the involved muscles. Once the diagnosis is suspected, prompt treatment by appropriate fasciotomy should result in maintenance of normal limb function.     

Reconstructive surgery of sequelae of compartment syndrome of the lower leg and/or foot. Presentation of a new classification

The sequelae of an undiagnosed insufficiently treated or unpreventable (by crush injury) compartment or postischemic syndrome, most often after lower leg fracture or popliteal artery injury, are caused by necrosis and contracture of the extrinsic foot muscles. Therefore claw toes, pes equinus or other forms, such as a severe pes equino varus related to the compartment involved will decide the kind of foot deformity. In cases of a combined compartment syndrome of the lower leg and foot, not only the extrinsic but also the intrinsic muscles especially the short flexors are involved, leading to extensive claw toeing of the hallux and the lesser toes as well. In the case of an isolated compartment syndrome of the foot one will see contracted hammer toes most often after open or third degree closed calcaneal fractures. A new classification of all the different deformities of the foot and ankle as sequelae of a compartment and/or postischemic syndrome, is introduced distinguishing 5 degrees of deformity. Between 1994 and 2006, a total of 66 patients with sequelae of a compartment and/or postischemic syndrome were treated at the Department of Trauma and Reconstructive Surgery of the University Hospital"Carl Gustav Carus" of the Technical University of Dresden. Patients with contract hammer toes after calcaneal fractures were seen most often (n=26). Another large group of 24 patients suffered from the sequelae of a compartment and/or postischemic syndrome of the extrinsic muscles of the superficial and deeper compartment of the flexor tendons, producing a severe pes equino varus. Less common (n=16) were the deformities caused by an isolated compartment syndrome, such as necrosis of the anterior tibialis, long extensor muscles, peroneal muscles or a combined compartment syndrome of the lower leg and foot.     

Exercise-induced chronic compartment syndrome of the first dorsal interosseous muscle of the hand: a case report

A 21-year-old welder experienced chronic pain in the region of the first dorsal interosseous muscle after strenuous activity involving his hand. Direct measurement of the tissue pressures within the first dorsal interosseous muscle revealed an elevation of compartment pressure after lateral key pinch activity. After surgical release of the compartment, the pressures returned to normal, and the patient's symptoms improved. Exercise-induced chronic compartment syndrome of the small muscles of the hand should be considered in patients who describe aching pain in the hand after strenuous activity.     

断肢断腕断掌再植后手内在肌挛缩51例分析

探讨断肢断腕断掌再植术后手内在肌挛缩的发病机理,结合临床经验提出分类、预防和治疗方法。方法:对51例断肢(腕、掌)再植,分别采用术中切开骨间肌肌筋膜、掌腱膜及腕横韧带;术后严重肿胀时早期切开骨筋膜室;缺血时间超过10小时者,除上述措施外尚须切断或部分切除拇收肌和骨间肌肌腹。结果:采用上述预防措施后,手内在肌挛缩的发生率明显降低。结论:本症重在预防,如能及时、果断地采取措施,效果良好。一旦发生中、重度手内在肌挛缩应尽早手术。     

Wiederherstellende Chirurgie der Folgezustände nach Kompartmentsyndrom des Unterschenkels und/oder Fußes

The sequelae of an undiagnosed insufficiently treated or unpreventable (by crush injury) compartment or postischemic syndrome, most often after lower leg fracture or popliteal artery injury, are caused by necrosis and contracture of the extrinsic foot muscles. Therefore claw toes, pes equinus or other forms, such as a severe pes equino varus related to the compartment involved will decide the kind of foot deformity. In cases of a combined compartment syndrome of the lower leg and foot, not only the extrinsic but also the intrinsic muscles especially the short flexors are involved, leading to extensive claw toeing of the hallux and the lesser toes as well. In the case of an isolated compartment syndrome of the foot one will see contracted hammer toes most often after open or third degree closed calcaneal fractures. A new classification of all the different deformities of the foot and ankle as sequelae of a compartment and/or postischemic syndrome, is introduced distinguishing 5 degrees of deformity. Between 1994 and 2006, a total of 66 patients with sequelae of a compartment and/or postischemic syndrome were treated at the Department of Trauma and Reconstructive Surgery of the University Hospital“Carl Gustav Carus” of the Technical University of Dresden. Patients with contract hammer toes after calcaneal fractures were seen most often (n=26). Another large group of 24 patients suffered from the sequelae of a compartment and/or postischemic syndrome of the extrinsic muscles of the superficial and deeper compartment of the flexor tendons, producing a severe pes equino varus. Less common (n=16) were the deformities caused by an isolated compartment syndrome, such as necrosis of the anterior tibialis, long extensor muscles, peroneal muscles or a combined compartment syndrome of the lower leg and foot.     

Surgical treatment and late results of foot compartment syndrome]

From 1982 to 1988 a total of 29 patients with compartment syndrome of the foot were treated by fasciotomy. The most common causes were fracture dislocations of the Lisfranc (n = 14) and Chopart joints (n = 4). Since these injuries lead to a severe damage to soft tissue structures--joint capsules, ligaments, fasciae--the muscular compartments often communicate and decompression can be achieved by a longitudinal dorsal incision of the skin and fasciotomy of the fascia dorsalis pedis and the retinacula extensorum superior and inferior. Subsequent measurement of intracompartmental pressure dictates whether blunt dissection of the interosseous muscles and separate fasciotomy of the medial, lateral and plantar compartments have to be performed. Follow-up was possible in 18 patients: half had good results, while 9 patients had limited motion of their toes and/or paresthesia. It is impossible to know whether these negative findings are caused by the compartment syndrome itself or by the severe soft tissue damage resulting from the initial trauma.     

First dorsal interosseous compartment syndrome

Compartment syndromes of the interosseous muscles in the hand are difficult to diagnose because of their atypical presentation, and are often not recognised, especially when the syndrome presents as a chronic affliction. Such a syndrome affecting the first dorsal interosseous muscle in a dominant hand, and undiagnosed for nearly eight years, is described. Simple fasciotomy proved to be the only definitive treatment necessary.     

Compartment Syndrome of the Arm After Cable-Wakeboard Accident

Abstract   A compartment syndrome is an increased tissue pressure within a closed osteofascial compartment. This compromises blood flow to the muscles and nerves within that compartment, which –if not treated adequately in an early stage-results in permanent tissue and nerve damage. It most frequently occurs in the lower leg, but can also occur elsewhere when muscles are enclosed in tight fascial compartments, such as the forearm and hand. In this report a patient is described who developed an acute compartment syndrome of the arm after a cable-wakeboard accident in which his arm was strangulated. Cable-wakeboarding is an extreme sport that has become very popular over the last years. Early recognition and treatment of an acute compartment syndrome is of extreme importance since in short term necrotic muscles can lead to severe irreversible complications. Accidents with cable-wakeboarding often occur during the start. This is caused by the strong forces that are on the cable during the start. Strangulation injuries of the arm can cause a compartment syndrome of the arm. Possibly a wet-suit or dry-suit offers some protection. However, the duration of strangulation determines much of the damage. Although diagnosis of a compartment syndrome can be difficult, a high index of suspicion combined with fast and adequate treatment with a fasciotomy improve outcome and prognosis.     

The quantification of the origin area of the deep forearm musculature on the interosseous ligament

The diagnosis and treatment of injuries involving rupture of the interosseous ligament remain challenging. Few studies have considered the effects of rupture of the interosseous ligament on deep forearm muscle function. The objective of this study was to quantify the attachment areas of the deep forearm muscles on the interosseous ligament. The origins of the extensor indicis, extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus, lexor pollicis longus, and lexor digitorum profundus were digitized from 11 cadavers. Three-dimensional modeling techniques were used to quantify the origin area on bone and the interosse- ous ligament. The extensor pollicis longus and the abductor pollicis longus attached primarily to the interosseous liga- ment (81% and 62%, respectively). Although the other deep forearm muscles had larger origins on bone, relatively large areas on the interosseous ligament were observed, ranging from 31% to 47%. The muscle origins on the interosseous ligament were veriied histologically, where striated muscle originated directly from the dense connective tissue of the interosseous ligament. Due to their relatively large attach- ment areas on the interosseous ligament, the function of the deep forearm muscles might be altered after an interos- seous ligament rupture. Therefore, symptoms such as pain and weakness of the deep forearm muscles could serve as a basis for screening patients with injuries of the interosse- ous ligament. Furthermore, the data may help to elucidate factors limiting the healing of the interosseous ligament. Future studies should focus on quantifying the effect of an interosseous ligament rupture on the function of the deep forearm muscles and developing reconstructions that con- sider this function.     

Compartment syndrome as a presentation of non-Hodgkin's lymphoma

An 80-year-old woman sustained an injury to her left leg and presented having a compartment syndrome. Biopsy at the time of fasciotomy revealed lymphoma infiltrating the muscles of the left leg. We conclude that tumors may present as compartment syndrome and should be included with the differential diagnosis.     

Anatomy and intracompartmental pressure measurement technique of the pronator quadratus compartment

The compartment of the pronator quadratus muscle in 25 cadaver specimens is described. Defined by the radius, ulna, and distal interosseous membrane dorsally and the pronator quadratus fascia on the palmar side, the osteofibrous walls of the compartment confine the pronator quadratus muscle within a noncompliant space. A safe and reliable location for compartment pressure measurement was defined at a site 4 cm proximal to the scaphoid tubercule, on the radial side of the flexor carpi radialis tendon and on the ulnar side of the radial artery. These clear anatomic definitions might be useful in diagnosis of compartment syndrome of the pronator quadratus; a clinical investigation may be justified on the basis of pressure measurements made using this technique.     

The posterior interosseous artery in the distal part of the forearm. Is the term "recurrent branch of the anterior interosseous artery" justified?

In 1993 Angrigiani raised the question as to whether the distal part of the posterior interosseous artery (AIP) is a recurrent branch of the anterior interosseous artery (AIA) and forms a "choke"--anastomosis with the AIP in the middle of the forearm. A dissection study was conducted on 66 upper extremities to evaluate the diameters of the dorsal branch of the anterior interosseous artery, the anastomotic branch, the diameter of the posterior interosseous artery at the point of origin of the septocutaneous perforators in the middle of the forearm and the diameter of the posterior interosseous artery at the point of emergence in the dorsal compartment. We further tried to identify different forms and types of the "distal" anastomosis and the connections to the dorsal carpal arch and the ulnar artery. A distal anastomosis between the AIA and AIP was found in 65 of the 66 upper extremities. Three different types of anastomosis could be identified. The smallest diameter was found at the middle of the forearm (mean diameter AIA 1.28 mm; anastomotic branch 0.6 mm; AIP at the middle of the forearm 0.39 mm; AIP prox. 1.35 mm). A branch through the fifth extensor compartment was present in all of our specimens (mean diameter 0.54 mm). A branch through the forth extensor compartment could be found in 16 specimens. Based on our findings and the embryological development, we conclude that the AIP is only present in the proximal half of the forearm. In the distal part, the dorsal branch of the anterior interosseous artery forms a vascular arcade, which gives off branches to the dorsal carpal arch, the ulnar head and the ulnar artery. This arcade anastomoses with the posterior interosseous artery in the middle of the forearm by means of a choke anastomosis. We also conclude that the term "recurrent branch of the anterior interosseous artery" for the distal part of posterior interosseous artery is correct.     

Belastungsinduziertes Kompartmentsyndrom der Peronealloge nach Bowling

A 30-year-old man presented several times with pain in the calf after twisting his foot and injuring it during bowling. It was some time before the diagnosis of acute exertion-induced compartment syndrome was made, and an immediate fasciotomy could no longer prevent necrosis of the peroneal muscles. Because of the patient's drop-foot, we performed a tibialis posterior tendon transfer, fixing it to the cuneiform bone. The sort of compartment syndrome observed after engagement in various sports is a recognised, albeit uncommon, variant of acute compartment syndrome. A high level of suspicion and observation is required to make the diagnosis when any leg pain has no definite diagnosis. Fasciotomy should be performed early.     

Electrophysiological diagnosis in ulnar nerve entrapment at elbow

Using "inching technique" we recorded antidromic sensory nerve action potentials from the little finger and compound muscle action potentials from the abductor digiti minimi, first dorsal interosseous and flexor carpi ulnaris muscles in 30 entrapped ulnar nerves. In cubital tunnel syndrome, localized conduction delay occurred most commonly at a point 2 to 4 cm distal to the medial epicondyle. In other ulnar neuropathies, with the exception of cubitus valgus deformity, conduction block or delay was noted at a site just distal to the medial epicondyle. These conduction abnormalities were most commonly observed in the abductor digiti minimi and first dorsal interosseous. In contrast, conduction abnormality in tardy palsy secondary to the valgus deformity reflected mainly in the flexor carpi ulnaris. This method provides useful information in diagnosing the early involvement and precise localization of nerve entrapment, and differentiation of cubital tunnel syndrome from other ulnar nerve entrapment.     

Anterior compartment pressure measurement in closed fractures of leg

Background:

Compartment syndrome is a potentially devastating condition. Increased intracompartmental pressure has been incriminated as the primary pathogenic factor in compartment syndrome. The purpose of this prospective study was to monitor the anterior compartmental pressure and differential pressure to minimize the incidence of acute compartment syndrome.

Materials and Methods:

Seventy-five consecutive cases of closed fractures of leg presenting within six hours of injury were taken for measurement of anterior compartment pressure at the level of fracture and at 5 cm and 10 cm away from the fracture site, using the Whitesides'' infusion technique. A differential pressure of less than 30 mm Hg was taken as the criterion for diagnosis of compartment syndrome.

Results:

Two patients (2.67%) developed acute compartment syndrome. The mean anterior compartment pressures were highest at the level of the fracture and went on decreasing as we went away from the fracture site, which was found to be statistically significant (P < 0.001).

Conclusion:

Compartment pressure measurement is the most reliable and objective method for early diagnosis of compartment syndrome. Whitesides'' infusion technique is a relatively easy and inexpensive method to come to a diagnosis of compartment syndrome in a developing country like India. Differential pressure is more reliable than absolute pressure in predicting the development of an impending compartment syndrome.     

Intersection Syndrome in a Handcyclist: Case Report and Literature Review

Intersection syndrome describes a rare inflammatory condition located at the crossing point between the first dorsal compartment muscles and the radial wrist extensor muscles. It is a repetitive motion injury that affects patients who overuse their wrists. The present report reviews the incidence of the condition as well as the special populations it affects. The anatomy of the wrist is presented and clinical findings and physical examination techniques are reviewed to help the reader reach a quick but correct diagnosis. Finally, the most appropriate treatment approach is presented, incorporating rehabilitative methods designed to ensure a full and prompt functional recovery and resumption of physical activity.Key words: handcycling, intersection syndrome, peritenosynovitis, spinal cord injury     

Value of early decompression in compartment syndrome of the burnt hand

Our experience with over one hundred burned hands has shown that the compartment syndrome is a frequent occurrence in the hand and fingers. It is often underestimated because clinical diagnosis is difficult and an infra-clinical ischaemia may exist although the pulse is present. We believe it is important to carry out systematically Whiteside's method of investigating pressure in the compartments of the hand. When pressure exceeds 40 mm Hg the interosseous compartments and sometimes the digital canals or even the antebrachial compartment should be opened. This simple technique followed by early excision and graft and intensive rehabilitation has in our experience transformed the prognosis of burned hands.     

小切口单纯肘管松解术治疗肘管综合征

目的 通过临床研究分析小切口单纯肘管松解术治疗肘管综合征的适应证。选择病程平均为2．5人月,无肘部骨折或畸形的9例男性患者进行手术。于尺神经沟作2－3cm长的小切口,仅切开肘管及其远端的弓状韧带,在尺神经鞘膜内注射1ml确炎舒松－A。结果 9例的手尺侧麻木感于术后1个月内消失,刺痛觉减退在术后半年恢复正常。2例骨间肌蚓关肌有轻度肌萎缩者在术后1年半完全恢复。结论 对肘部无骨折畸形,病程短,无明显肌萎缩,爪形手畸形的肘管综合征可以采用小切口单纯肘管松解要治疗。     

Acute noncontact compartment syndrome

Although acute compartment syndrome is considered a surgical emergency, controversies exist regarding diagnosis, surgical indications, and techniques of management. Acute compartment syndrome is associated with numerous causes, including fractures, crush injuries, burns, soft tissue injuries, and vascular trauma. Prolonged positioning of an extremity has not been previously described as a cause of compartment syndrome. The authors present a case of an acute compartment syndrome occurring because of prolonged extrication after a motor vehicle accident and without direct trauma to the involved extremity.     

Massive ventral hernias: role of tissue expansion in abdominal wall restoration following abdominal compartment syndrome

Massive ventral hernias may result from a variety of clinical situations. One such clinical situation, a common problem in trauma patients, is abdominal compartment syndrome. Abdominal compartment syndrome frequently results in a massive abdominal defect when primary closure after surgical decompression is not possible. We offer a technique for repairing these massive ventral hernias by first expanding the lateral abdominal wall muscles, fasciae, and skin with tissue expanders and then closing the defect with elements of the "components separation" method. Additionally we present other clinical situations resulting in a massive ventral hernia that were repaired using this technique.