3. DEFENITION
• A syndrome consisting of ischcaemic necrosis of the
muscles of the anterior tibial compartment of the leg,
with a lesion of the anterior tibial nerve.
4. INTRODUCTION
• The phrase the "anterior tibial syndrome" was first
used to describe a condition observed in healthy
young men.
• The features were pain in the front of the leg followed
by ischaemic necrosis of the anterior tibial group of
muscles.
5. • The condition was first mentioned by P. R. Vogt.
• It is occurring in fit young men.
• During or after strenuous physical activity such as a
game of football, marching, or jumping, -pain
develops in the anterior tibial region.
7. • Spasm of anterior tibial artery may occur.
• Common peroneal nerve is involved by
compression
8. Clinical features
EARLY STAGE
• Intense pain in the front of the leg, shortly after exercise.
• The pain does not relieved on rest .
• Followed by tenderness on pressure over the underlying
muscles, which feel firm, redness of the overlying skin, and
slight local oedema.
9. STAGE OF PARESIS
• If the condition is not relieved the affected
muscles become paralysed and the patient is
unable to dorsi-flex the foot or toes. (paresis )
• Foot-drop may not be obvious because of
contracture of the muscles.
• Usually confined to one leg.
10. • All muscles of the anterior tibial group may
not be equally affected.
• Tibialis anterior and extensor hallucis longus
are involved
• But extensor digitorum longus may be only
partly affected.
11. Predowitz etal Diagnostic criteria for anterior tibial
syndrome
• Pre - exercise resting pressure of 15 mm of Hg or
more.
• Pressure of 30 mm 0f Hg or more after 1 minute of
exercise.
• Pressure of 20 mm of Hg or more after 5 minutes of
exercise.
12. TREATMENT
• This condition can be prevented by graduated
physical training. Or
• To stop complete athletic activities.
• When the full blown syndrome occurs Surgical
decompression of the anterior compartment
should be executed as an emergency procedure.
13. Single incision fasciotomy
• Anterior and lateral
compartment s are released
by a same incision
• 5 cm longitudinal incision
half way between the fibula
and the tibial crest.
14. • Identify the superficial
peroneal nerve and
inter-muscular septum .
• Pass a fasciotome in the
line of anterior tibial
muscles.
15. • In the lateral compartment
,run the fasciotome
posterior to the superficial
peroneal nerve in line with
the fibular shaft.
• After releasing the
compatment
• Close the skin by sutures.
16. Double mini incisional fasciotomy Mouhsine
etal
• Without use of tourniquet
• Make two vertical incisions of 2 cm size with 15 cm
distance
• Development of subcutaneous flap with blunt
dissection
17. • Skin retraction to allow
fasciotomy under direct
vision.
• Wound closure after
release
18. After treatment
• Early range of motion exercise are encouraaged
• Weight bearing on tolerance - crutches are allowed the
day after surgery.
• Crutches are discarded when walking without difficulties.
• Jogging is allowed at 2-3 weeks if swelling and
tenderness are absent.
20. DEFENITION
• Episodic digital ischemia manifested clinically
by the sequential development of digital
blanching ,cyanosis, and rubor of the
fingers/toes after the cold exposure.
21. CLASSIFICATION
• Primary Raynaud’s / Raynaud’s disease the
causes is not known.(Idiopathic)
• Secondary Raynaud’s / Raynaud’s
phenomenon where the causes are known.
22. PATHOGENESIS
Exaggerated Vasomotor Response
Expose to cold /
triggering factor
Digital arteries at
fingers and toes
vasospasm
Become pale, less
blood flow and low
O2 supply
Capillaries/venules
dialate
Cyanosis due to
deoxygenate blood
Rewarming-
(arteries dilate)
Blood flow increase,
high O2 supply
Reactive
hyperemia- Color
change to bright
red
Affected area is
warm and
throbbing pain
23.
24. PRIMARY REYNAUDS DISEASE
• Idiopathic
• 50 % of reynauds include primary
• It often develops in young women in their teens and early
adulthood.
• Male : female = 1:5
• Age- between 20 & 40 years
• Figers > Toes
• One or 2 finger tips entire finger all fingers in subsequent
attacks
25. • Rarely ear lobes/tip of the nose.
• Smoking worsens frequency and intensity of attacks.
• Caffiene also worsens the attacks.
• Associated disease: migrane and angina (vasospstic
disorders)
• Spontaneous improvement in 15%
• Progressive disease in 30%
30. Clinical features or Raynaud’s
• Primarily affects fingers
• Episodes precipitated by cold exposure
and emotional stress
• Episodes accompanied by pain with or
without numbness
• Pulses present
Initial
ischaemia
Pallor
Cyanotic
phase
Blue
Hyperaemic
phase
Red / purple
32. • Chronic, recurrent cases of Raynaud phenomenon can result
in atrophy of the skin, subcutaneous tissues , and muscle.
• In rare cases it can cause ulceration and ischemic
gangrene.
34. Acrocyanosis
• Persistent, painless, symmetric cyanosis of the hands, feet, or
face
• Caused by vasospasm of the small vessels of the skin in response
to cold.
• The digits and hands or feet are persistently cold and bluish,
sweat profusely, and may swell.
• Cyanosis persists and is not easily reversed,
• Trophic changes and ulcers do not occur,
• Pain is absent.
• Pulses are normal.
35. DIAGNOSIS
• Raynaud’s phenomenon can be diagnosed on clinical
grounds.
• Imaging studies, including thermography, isotope studies,
and arteriography can be done .
• None has proven superior to clinical assessment.
• However, patients with a fixed, nonreversible, cyanotic
lesion require further evaluation of the vasculature.
38. Safety Measures
• Avoiding direct contact with frozen foods or cold drinks
• Insulation against cold and local warming, including gloves
• Heavy socks and electric and chemical warming devices
• Avoiding smoking
• Discontinuing drugs that may provoke vasospasm
39. Treatment
• Secondary Raynaud’s: Treatment of the underlying
disease
• Primary Raynaud's: Avoiding triggers.
– Extreme Cold Exposure
– Caffeine
– Coffee
– Avoidance of Emotional Stress
40. Emergency Care:
– Allow slightly warm water to run over the affected digits
and gently massage the area.
– Continue this process until the white area returns to its
normal, healthy colour.
– Place the affected digits in a body cavity—armpit, crotch,
or even the mouth.
– Vigorous hand movement will allow the blood circulation
to increase
41. Drug Therapy:
• Calcium Channel Blockers like Nefidipine can be given
• Sildenafil can improve the microcirculation and
relieves symptoms in patients with Secondary
Raynaud's phenomenon resistant to vasodilator therapy
• Topical nitroglycerin (1% or 2%) local application.
• N-acetylcysteine – In patients with systemic sclerosis and
digital ulcers
43. References
• Mercer text book of orthopaedics 8th edition
• Campbells operative orthopaedics 11 th Edition
• Campbells operative orthopaedics 12 th Edition
• Crawford Adams outline of orthopaedics
• Natarajan text book of orthopaedics
• D C Watson ; British medical journal,Anterior
Tibial syndrome following arterial
embolism:1412-1413 June 1955,
