Lower Extremity Compartment Syndrome
Carlos A Sagebien Orthopaedic Traumatology University Orthopaedic Associates Robert Wood Johnson UniversityHospital Disclosures
–No conflicts to disclose
www.UOANJ.com Overview
1. History 2. Define compartment syndrome 1. Exercise Induced (Chronic Exertional Compartment Synd) 2. Traumatic 3. Relevant anatomy 4. Clinical Pathophysiology 5. Diagnosis 1. Physical Exam 2. Studies 6. Treatment
www.UOANJ.com History
• Wilson: first described it on trek at Antarctica • Vogt: 1943 “March Gangrene” • French/Price: 1962 first documentation of elevated compartment pressures as cause of compartment syndrome • Mavor: 1956 fasciotomy described for Tx
www.UOANJ.com Definition
• Exercise Induced Compartment Syndrome (CECS) – Pain with exercise that subsides with rest – Increased pressure within a closed space • Decreased tissue perfusion that causes ischemic pain • Subsides quickly with rest • No permanent damage to tissues • History of repetitive episodes with exertion
www.UOANJ.com Definition
www.UOANJ.com Definition
• Acute Traumatic Compartment Syndrome – ACUTE increased pressure within a closed space • Compartment pressure exceeds perfusion pressure • Tissue damage common • Progressive with time, rarely decreases with time • History of significant trauma
www.UOANJ.com Definition
www.UOANJ.com Relevant Anatomy
• Four myofascial compartments in the leg – Anterior (Ankle and toe extensors) – Lateral (Ankle eversion) – Posterior Superficial (Gastrocsoleus complex) – Posterior Deep (Ankle and toe flexors)
www.UOANJ.com Relevant Anatomy
www.UOANJ.com Incidence
• 14 to 27% of the population may experience episodes of CECS* – Male preponderance – Most studies on military/athletic programs • (Likely similar rates male:female)
*Birtles DB, Minden D, et al. Chronic exertional compartment syndrome: muscle changes with isometric exercise. Med Sci Sports Exerc. 2002; 34: 1900-6.
www.UOANJ.com Clinical Pathophysiology
• Increased compartment pressure – Arterial spasm/decreased inflow – Capillary obstruction – Arteriovenous collapse – Decreased venous outflow
www.UOANJ.com Clinical Pathophysiology
• Muscles swell by 20% with exercise – Normal: baseline by 5 minutes – CECS: remains swollen 30 minutes or more
www.UOANJ.com Diagnosis
• History – Sports with increased running (soccer/basketball) – Symptoms occur predictably (time/effort) – Symptoms dissipate predictably with rest – Rarely last long term (hours) after rest
www.UOANJ.com Diagnosis
• History – Dull ache within 30 minutes – Increases in intensity with activity • Tightness • Burning • Fullness • Radiation (nerves involved) – Frequently causes cessation of activity
– Bilateral 80-95%* *BongMR,PolatschDB,JazrawiLM,RokitoAS.Chronic exertional compartment syndrome: diagnosis and management. Bull Hosp Jt Dis 2005; 62: 77-84.
www.UOANJ.com Diagnosis
• History: Acute: 5 “P”s 1. Pain out of proportion** 2. Paresthesias 3. Poikilothermia 4. Pallor 5. Pulselessness • Firm compartments • Shiny skin • Patient in extreme pain
www.UOANJ.com Diagnosis
• Physical Exam – Anterior and lateral compartments present with pain over the anterior lateral aspect of the leg and may radiate to the ankle or foot dorsally. – The anterior compartment is involved in 40-60% of patients and the lateral in 12-35% of patients.
www.UOANJ.com Diagnosis
• Physical Exam – Deep posterior pain and tibialis posterior pain is located at the posteromedal border of the tibia and may radiate to the medial aspect of the foot. – The deep posterior compartment is involved in 32- 60% of patients. – A minority of patients will report pain superficially and have a 2-20% involvement.
www.UOANJ.com Diagnosis
• MRI – Good specificity and sensitivity – Non-invasive – Increased signal on T-2 images
www.UOANJ.com Diagnosis
• Near Infrared Spectroscopy (NIRS) – Measures Hemoglobin oxygen saturation of deep tissues – Decreased O2 in CECS – Non-invasive
www.UOANJ.com Diagnosis
• Intracompartmental Pressures – Gold standard, However….. • Learning curve • Invasive • Difficult to perform in office • Difficulty with anatomy
www.UOANJ.com Diagnosis
• Pedowitz et al, 1990 – The diagnosis is based on having 1 of 3 of the following: 1. A pre-exercise pressure of ≥15 mmHg 2. 1 minute post-exercise pressure of ≥30 mmHg 3. 5 minute post-exercise pressure of ≥20 mmHg * Increased confidence if 2/3 or 3/3 criteria met
www.UOANJ.com Differential Diagnosis DIAGNOSIS SYMPTOMS CECS Pain starts within first 30 minutes of exercise and can MRI/NIRS/ICP radiate to ankle/foot. Pain ceases when activity is stopped
Medial Tibial Stress Syndrome Pain along posteromedial aspect of mid and distal tibia. Bone Scan Exacerbated by activity and only partially relieved by rest.
Stress Fracture Localized area of pain over tibia or fibula initially relieved Bone Scan,MRI by rest. Usually occurs after change in training routine.
Fascial Defects Often asymptomatic. Exam/MRI
Nerve Entrapment Syndromes Parasthesias and burning pain along involved nerve EMG/NCS distribution. Can be associated with weakness.
Radiculopathy Radiating pain at rest that follows a specific dermatone. Lumbar MRI Can be associated with weakness, parasthesias.
Vascular Claudication Rare cause of leg pain in healthy adults. Popliteal artery
ABI/Angiogram www.UOANJ.com Treatment
• Activity Modification – Take up a new sport!
www.UOANJ.com Treatment
• Activity Modification – Forefoot strike running technique – 19 patients – Baseline and 6 week measurements after home intervention running program • 43% improvement in rate of CECS • 36% reduction in pressures
www.UOANJ.com Treatment
• Botox – Botulinum toxin injected in 16 patients – 4.4 +/- 1.6 month follow-up – Exertional pain completely gone in 15 patients – Decreased strength in patients • No functional consequence – Mode of action unclear – Long-term????
www.UOANJ.com Treatment
• Open Fasciotomy – Gold standard – Lateral incision • Anterior and Lateral compartments (S. peroneal nerve) – Medial incision • Deep and superficial compartments (Saphenous N/V)
www.UOANJ.com Treatment
• Open Fasciotomy
www.UOANJ.com Treatment
• Endoscopic Fasciotomy – Good visualization of the structures – Smaller incisions
www.UOANJ.com Treatment
• Fasciotomy – Regardless of technique >90% success • Deep posterior less successful than anterior/lateral – 4.5-13% complication rate • Hemmorhage • Hematoma • Infection • Nerve injury • DVT • Recurrence (3-12%)
www.UOANJ.com Summary • Chronic exertional compartment syndrome is an uncommonly encountered problem. • Diagnosis and management challenging. • Need to know anatomy/compartments of the lower leg. • Proper history and physical that is backed with both pre- and post-exercise intra-compartmental pressures • Fasciotomy is the standard of care for athletes unwilling to modify/change actitivities
www.UOANJ.com Summary • How a trauma surgeon does CECS fasciotomy!!
www.UOANJ.com Thank You
Carlos A. Sagebien MD Orthopaedic Traumatology/Fracture care University Orthopaedic Associates (609)651-2548: Cell phone
www.UOANJ.com