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Compartment Syndrome Craig Young MD

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Compartment Syndrome Craig Young MD Compartment Syndrome Craig Young MD Case 1 35 yo runner Foot drop and tingling in 1st web space Only when running pace < 5 mim/mile Do you think this person has exertional compartment syndrome? If yes, which compartment? Basic physiology Average capillary pressure ~ 25 mm Hg Normal interstitial pressure 4-6 mm Hg Capillaries collapse in ~30 mm Hg Hypoxic injury causes cells to release vasoactive substances (e.g. histamine, serotonin Increase endothelial permeability. Increases fluid leakage, which increases tissue pressure and advances injury Exertional compartment pressure measurements Measurement Pressure (mm Hg) Resting Normal < 12 Suspicious > 15 1 min post-exercise Normal < 20 Suspicious 20 - 30 Diagnostic > 30 5 min post-exercise Normal < 12 Suspicious 12 - 20 Diagnostic > 20 Common locations Anterior compartment of calf (40-50%) Extensor muscles (Tib Ant, EDL) Ant tibial a & v Deep peroneal n (Dorsal 1st web space) Deep posterior compartment (30-40%) Deep flexor muscles (FDL, Tib Post, FHL) Post tib a& v; Peroneal a & v Tibial nerve (plantar foot) Other locations Lateral compartment of calf (20%) Peroneus longus & brevis Superficial peroneal n lateral lower leg dorsum of foot (check between 3rd & 4th metatarsals) Rare locations Superficial posterior compartment of calf Gastrocnemius, plantaris & soleus Sural nerve – Provides sensation to the lateral aspect of the foot and distal calf Forearm Volar - rare Dorsal - extremely rare Mobile wad of Henry (brachioradialis, ECRB & L) Hand Case 1 results PE - wnl Anterior compartment measurements Resting - 8 mm Hg 1 min p exercise - 32 mm Hg 5 min p exercise - 22 mm Hg What treatments would you consider for this patient? Non-surgical treatment Removal of constricting equipment or clothing Relative rest Shorting stride Forefoot/midfoot strike Better cushioned shoes Zero drop/Barefoot shoes Stretching and massage Surgical treatment Gold standard Fascial release Fasciotomy Image from eMedicine Case 1 treatment In middle of workup his wife became pregnant Decreased mileage and racing Asymptomatic 8 years later started racing again Symptoms returned with racing Surgery Asymptomatic Case 2 43 year old referred for compartment testing from a surgeon up North Complains of pain from knee to mid shin Pain is usually present Denies any numbness or weakness Do you think this person has compartment syndrome? 3 categories I think you have ECS I don’t think you have ECS You might have ECS Epidemiology Usually younger athletes Usually endurance athletes Often bilateral Presentation Localized aching pain Feeling of fullness Onset with specific effort Rapid resolution with rest (within 20 min) Associated weakness and numbness Examination Usually normal at rest After exercise Increased firmness of compartment Pain with passive motion or stretching of compartment Bob Dimeff ’s clinical pearl Ask subject to rate pain (1-10) of slowly injected Marcaine into test sites if high rating ≥ 7 Almost always negative (i.e. less likely to be exertional compartment syndrome) ≤ 3 all have been positive Slit catheter system 18 gauge needle Case #2 Results of Case Normal pressures Case #3 Professional soccer player Took a kick to lateral ankle in practice the day before Now c/o pain and swelling over the lateral ankle Difficulty walking Numbness on dorsum of foot Do you think this person has exertional compartment syndrome? Acute compartment syndrome Signs & symptoms Poikilothermia - cool extremity often earliest sign of impending compartment syndrome Pain To passive motion Out of proportion to exam Painful, tight/tense compartment to palpation/squeeze Paresthesias Pulselessness & pallor - rare Surgical emergency Acute compartment pressure measurements Pressure 0-10 mm Hg Normal 10-30 Elevated 30-40 Potentially dangerous 40-60 Usually dangerous 60+ Consistently dangerous Case 3 Results Elevated lateral compartment pressure Taken to surgery Clot found occupying a large portion of the lateral compartment Back to playing soccer with no residual symptoms Summary Acute compartment is surgical emergency If it doesn’t seem classic think twice before sticking Leg pain of unknown etiology may represent chronic compartment syndrome Should involve whole compartment Unless variant anatomy In Season Management of PF Injuries Elizabeth A. Arendt Professor & Vice Chair University of Minnesota Department of Orthopaedic Surgery SPORTS MEDICINE I have no conflicts of interest with this talk. In Season Management of PF issues • PF instability – Primary ( first time) – Recurrent – With cartilage damage by MR • PF Cartilage Damage w/out Instability – Patella – Central groove defect Partnership Approach Weighing the Options Risks Benefits Working together to find the best solution For all cases • Eliminate swelling (ideal) before return to practice – (Minimum) no increase in swelling w/ training • Symmetric Strength & LSI on functional tests • Confident in Sport Movement – Observed – Self reported ( Mental outcome scores) PF Instability Primary Dislocation : •Risk of second dislocation – 17 % (Fithian – Kaiser data) – 33 % ( U of M data) Recurrent Dislocation: •Risk of additional dislocation: – 49% (Fithian – Kaiser data) – 70% + in some studies Primary LPD – no cartilage damage • Favor more restrictive RTP scenario to guard against second patella dislocation. • Aggressive attention to faulty movement mechanics • MPFL repair : no in my surgical algorithym • If RTP in season would protect with knee sleeve and / or taping • Favor McConnell over Kinesio Recurrent LPD – No Cartilage Injury • Favor RTP using standard criteria • If RTP in season would protect with knee sleeve and / or taping • Favor McConnell over Kinesio •Consider MPFL reconstruction @ season end • If needs bony surgery to stabilize (distal TTT): • RTP might take > 9 mo. (? Next season?) Recurrent LPD: Established Cartilage Wear • Try to distinguish between – Acute chondral injury • Usually uni-polar • No sclerosis • (Usually) recent injury – Chronic injury • History of ‘problems’, often ignored • History of current &/or remote injury • MRI: sclerosis &/or cysts Treat Chondrosis and Arthrosis Differently?? • Chondrosis: – Softening of the cartilage – Usually uni-polar, focal – Etiology varied • Arthrosis: – cartilage wear – Usually bi-polar, diffuse – Etiology varied Case History #1 • Junior IC tennis player • H/o LPD age 14, reduced in ER • Cont’d to play tennis at high level • ‘Some’ problems, no more LPD • 2nd LPD spring / 2nd year not reported to MD • Want to play pro after college Complaints: • Swelling w / confidence • No pain • No further dislocations. • Trochlear Dysplasia Type D • Good engagement between patella and trochlea cartilage MR PF Risk Factor Measurments • TT-TG 21mm (20mm) • Tilt 22 ° (20º) • C/D 1.3 (1.2) • PTI 0.3 (.I2) Patella cartilage wear 25mm x 15 mm Bipolar disease (patella and groove) Case History #1 • Needed bony procedure to optimize PF joint function • Chondral wear on – going and (formerly) well tolerated • Major surgery w/ +/- cartilage restoration not likely compatible with professional career • Advise on future prognosis • Revise / modify training regiment • Give athlete time to accept her knee function and be honest with herself Case History #1 • Allowed play using swelling as guide • Optimized body mechanics • More realistic about # games played in tournaments • Injected with Synvisc, no chronic NSAIDS • Is re-evaluating her future ( 4-6 mo. Journey) No History of LPD: (+) Cartilage Wear Case # 2 • Junior IC W Gymnast • All-rounder, lead point scorer • No h/o PF instability • C/o swelling & ‘instability’ w/ 6 wks. left to season • MRI obtained Case History #2 Imaging Case # 2 In Season Management • Cortisone x 1 with 5 days rest • Severely restrict practice to those activities that do not cause swelling • Use of oral toradol on game day • Use of knee sleeve • Scope at season end • Scoped at end of season • Debridement with ACL biopsy Post Op Discussion • One year left, does not plan on remaining in competitive Gymnastics post college career. • Wants to finish Senior year as all rounder (ideally) • Agreed to reduce training year long & possibly give up vault if needed (most symptomatic event) Case # 2 – Finale • Managed last season as all rounder w/ multiple PB and awards • Used knee sleeve and NSAIDS in season • End of season discussion: – No knee swelling 1 mo. post season – Continues with “Zumba” like exercise routines • Does not want further surgery at this time, is satisfied w/ knee function Case #3 • Freshman F VB player – defensive specialist • First LPD 6th grade. • Scoped 2006 (11th grade): Grade 4 changes noted on LFC and lateral patella facet • Dislocated (?) pre-season as a Freshman (2008) • MRI ordered. Case # 3 • Tilt 22 degrees • Imagine the MRI • TT-TG 17 mm Case # 3 Normal Patella Height. Mild Trochlear Dysplasia No “knee’ arthritis or malalignment Case #3 • Treated symptomatically with NSAIDs/ knee sleeve / relative rest / CORE • Persistent swelling remained • No further “dislocations” • Played thru her symptoms with us monitoring her knee, rarely complained. • Scoped at end of Freshman year Case #3 Surgical procedure 12/2008 • Patella debridement • Lateral femoral condyle microfracture • Partial lateral facetectomy • Lateral retinacular lengthening w/ medial imbrication. Case # 3 – scope Grade 3-4 lateral patella facet Grade 3-4 lateral femoral condyle Case #3 – OR report • 2008 • Patella debridement • Lateral
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