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Chronic Exertional Compartment Syndrome (Henry Ford Health System)
- 1. Gonzalo Samitier MD PhD Orthopaedic Sports Medicine Fellow Henry Ford Health System EXERTIONAL COMPARTMENT SYNDROME Upper and Lower extremity
- 2. • What • Who • Where • Why - Leg - Thigh - Foot - Gluteus - Erector spinae - Forearm LOWER - Runners - Basketball - Soccer - Skiers UPPER - Motocyclist - Mountaineering - Weightlifting - Rowers - Martial arts - Wheelchair athletes ATHLETES WORKERS MILITARY - Muscle Hyperthrophy - Fascial thickening - Fascial inflexibility - Fascial hernias - Arteriole regulation - Inherent susceptibility
- 4. Medicine is a science of uncertainty and an art of probability” William Osler
- 5. Signs - Pain - Tightness - Increased tension - Fascial herniations - Muscle athropy or normal circunference - Cramping - Burning - Aching - Numbness sensory nerve territory - Tingling - Radiating symptoms distally - Weakness motor nerve territory - Reduced athletic perfomance If you don´t think about it you don´t diagnose it … Symptoms
- 6. DIFFERENTIAL DIAGNOSIS Bone stress syndrome Stress fractures Muscular cramps or ruptures Fascial defects Nerve Entrapment Syndromes Vascular entrapment syndromes Vascular claudication Radiculopathy Spinal Stenosis Deep Venous Thrombosis OTHERS Hypothyroid Myop Myopathies Tenosynovitis Tumor Infection
- 7. DIFFERENTIAL DIAGNOSIS WORKUP Blood and Urine Studies Extremity Imaging studies Electromyography Serum creatine kinase (CK) and myoglobin level (identifies myopathy or rhabdomyolysis) Urinalysis (UA) and urine myoglobin (rhabdomyolysis) D-dimer level (deep venous thrombosis) Complete blood cell count with differential (infection, osteomyelitis) Complete metabolic panel (metabolic derangements, acidosis, hypercalcemia, hyperkalemia) Thyroid-stimulating hormone (thyroid myopathy) Erythrocyte sedimentation rate (ESR) (infection, rheumatologic conditions) Rx, Bone Scan, CT, MRI
- 9. COMPARTMENT PRESSURE TESTING “ NOT EASY BEING PRECISE AND ACCURATE “ DIAGNOSIS
- 10. COMPARTMENT PRESSURE TESTING Recommend only the confidence limits from the studies in this review It is not possible in this review to comment on the best diagnostic thresholds for a particular protocol that maximizes both specificity and sensitivity. Roberts, A. Franklyn-Miller. The validity of the diagnostic criteria used in chronic exertional compartment syndrome: Systematic review. Scand J Med Sci Sports 2011
- 11. COMPARTMENT PRESSURE TESTING • Pedowitz criteria (One or more required): – Rest pressure > 15 mm Hg – 1-minute postexercise > 30 mm Hg – 5-minute postexercise > 20 mm Hg
- 12. COMPARTMENT PRESSURE TESTING • Measure pre and postexertional • Measurements must be made in all compartments of bilaterally • Marginal readings must be followed with repeat physical exam and repeat compartment pressure measurement • Personal Protocol with readings in controls • Use ultrasounds in deep posterior compartment RECOMMENDATIONS
- 13. COMPARTMENT PRESSURE TESTING • Infusion – manometer – saline – 3-way stopcock (Whitesides, CORR 1975) • Catheter – wick – slit wick • Arterial line – 16 - 18 ga. Needle (5-19 mm Hg higher) – transducer – Monitor • Manufactured devices – Stryker (Side port needle) – Synthes (cannula and probe)
- 15. COMPARTMENT PRESSURE TESTIING • Simple Needle – 18 gauge – Least accurate – Usually gives falsely higher reading • Slit Catheter and Side ported needle – No significant difference – More accurate Side port Moed et al JBJS 1993
- 19. FOREARM ANATOMY
- 20. ANATOMY THIGH
- 23. TREATMENT • Conservative • Surgical Fasciotomy +/- Fasciectomy - Single incision - Doble incision - Miniopen (Endoscopic assisted) • Physical Therapy • Proper Training techniques • Muscle imbalance • Aquatic Therapy • Pt. Education • Flexibility training • Manual- deep tissue work • NSAIDs and Diuretics ANTERIOR AND LATERAL COMPARTMENTS POSTERIOR COMPARTMENTS IDEALLY OPEN ONLY AFFECTED COMPARTMENTS
- 35. POSTOP • Early movilization • Include pool or cycling after wound healing • Isokinetic muscle strengthening exercises at 3-4 weeks • Full activity introduced at 6-12 weeks
- 36. RESULTS LOWER • Anterior and lateral comp: 65-100% success • Posterior comp: 50-75% success UPPER 95% satisfied patients
- 37. COMPLICATIONS • Hemorrage • Wound infection • Nerve entrapment • Swelling • Lymphocele • Peripheral nerve injury • Deep vein thrombosis • Recurrence
- 38. SURGICAL DESCOMPRESSION FAILURE • Misdiagnosis • Inadequate descompression • Inadequate affected compartment selection • Scarring
- 40. Think about it and rely on HPI and PE and rule out outsiders
- 41. Compartment pressure testing Gold Standard with a proper technique
- 42. Know your anatomy and open just the affected compartments
- 44. MADRID
- 45. MADRID