Compartment Syndrome 2LT Larson 2LT Loomis

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  • -During exercise, there can be a 20% increase in muscle volume as well as possible tissue edema.
    -As these fascial compartments have a limited ability to expand and accommodate the increased muscle volume, the pressure inside these compartments increases with strenuous exercise.
    CECS is most commonly linked to ischemia of the involved muscles resulting from the increase in intracompartmental pressure.
    Theories of Ischemia (bottom line: Decreased Blood Flow):
    -arterial spasm resulting in decrease of arterial inflow
    -arteriole or venous collapse due to pressure disturbances
    -When pressure in a compartment increases, the decreased vascular supply to the nerves can also be affected causing parethersias to occur
  • -Monitoring of pressures is usually done with wick catheter or slick catheter that allow pre and post exercise testing. Needle tip location and depth of penetration, as well as knee and ankle position are controlled to obtain valid and reliable measurements.
    (Both methods have proven equally reliable)
    -Normal intracompartmental pressure is between 0 and 8 mm Hg
    -An extended delay in normalization of pressures after exercise is also significant
  • Compartment Syndrome 2LT Larson 2LT Loomis

    1. 1. Compartment SyndromeCompartment Syndrome 2LT Larson2LT Larson 2LT Loomis2LT Loomis 1LT Moravec1LT Moravec
    2. 2. AGENDAAGENDA Introduction/PurposeIntroduction/Purpose Involved AnatomyInvolved Anatomy EtiologyEtiology Clinical Presentation and DxClinical Presentation and Dx Treatment/InterventionTreatment/Intervention ConclusionConclusion
    3. 3. INTRODUCTIONINTRODUCTION Compartment Syndrome can be a life/limbCompartment Syndrome can be a life/limb threatening emergencythreatening emergency Related to acute trauma or exertionRelated to acute trauma or exertion Affects the muscle tissue, innervation, andAffects the muscle tissue, innervation, and vascularization within a MS compartmentvascularization within a MS compartment Has also been described in the foot, thigh,Has also been described in the foot, thigh, forearm and gluteal regionsforearm and gluteal regions
    4. 4. Types of CSTypes of CS Acute Compartment SyndromeAcute Compartment Syndrome Exertional Compartment SyndromeExertional Compartment Syndrome  Acute-one time episodeAcute-one time episode  Chronic- with activityChronic- with activity
    5. 5. Under Pressure?Under Pressure? From Anatomy we all know the CruralFrom Anatomy we all know the Crural Fascia is VERY tight and has a limitedFascia is VERY tight and has a limited ability to expandability to expand Increased compartmental pressure canIncreased compartmental pressure can result in ischemia, neuropraxia and ifresult in ischemia, neuropraxia and if sustained, tissue NECROSISsustained, tissue NECROSIS
    6. 6. EtiologyEtiology Acute CS:Acute CS:  Direct trauma = Fx or soft-tissue injuryDirect trauma = Fx or soft-tissue injury  More common in men (McQueen et al)More common in men (McQueen et al)  Initial injury leads to swelling withinInitial injury leads to swelling within compartmentcompartment  Muscle damage theorized to increasesMuscle damage theorized to increases osmotic pressure from release of protein-osmotic pressure from release of protein- bound ionsbound ions
    7. 7. EtiologyEtiology Exertional CS:Exertional CS:  Overexertion-Overexertion- Associated with repetitiveAssociated with repetitive axial loading (runners and competitiveaxial loading (runners and competitive skaters)skaters)  Muscle volume can increase up to 20% due toMuscle volume can increase up to 20% due to fiber swelling and blood filling from vigorousfiber swelling and blood filling from vigorous exerciseexercise
    8. 8. EtiologyEtiology Chronic ECSChronic ECS (most commonly in Deep(most commonly in Deep Compartment):Compartment): No anatomical predispositionNo anatomical predisposition has been provenhas been proven Excessive compensatory pronation of theExcessive compensatory pronation of the subtalor joint implicatedsubtalor joint implicated  During gait this would increase activity ofDuring gait this would increase activity of deep posterior compartment musclesdeep posterior compartment muscles Usually bilateral involvement (50%-70%);Usually bilateral involvement (50%-70%); one extremity usually more symptomaticone extremity usually more symptomatic
    9. 9. CLINICAL PRESENTATIONCLINICAL PRESENTATION Pnt c/o severe painPnt c/o severe pain out of proportion toout of proportion to injuryinjury Pain aggravated byPain aggravated by passive musclepassive muscle stretchstretch Loss of sensationLoss of sensation may be useful signmay be useful sign Dorsalis pedis pulseDorsalis pedis pulse may or may not bemay or may not be affectedaffected http://www.physsportsmed.comhttp://www.physsportsmed.com
    10. 10. CLINICAL PRESENTATIONCLINICAL PRESENTATION Leg pain described as a dull acheLeg pain described as a dull ache (localized or diffuse) that begins at a(localized or diffuse) that begins at a predictable time during exercisepredictable time during exercise May also have:May also have:  FootdropFootdrop  Giving away of the ankleGiving away of the ankle  Paraesthesias in the footParaesthesias in the foot  Taut, shiny, warm skin that is TTPTaut, shiny, warm skin that is TTP
    11. 11. CLINICAL PRESENTATIONCLINICAL PRESENTATION Post-exercisePost-exercise  Involved compartments are swollen and tenseInvolved compartments are swollen and tense  Increased leg girth over involved musclesIncreased leg girth over involved muscles  Passive stretching of involved muscles mayPassive stretching of involved muscles may increase painincrease pain  Symptoms usually lessen within 30 minSymptoms usually lessen within 30 min
    12. 12. Differential DiagnosisDifferential Diagnosis Rule outRule out stress fracturesstress fractures oror periostitisperiostitis  Radiographs, bone-scan, bony tendernessRadiographs, bone-scan, bony tenderness Medial tibial stress syndromeMedial tibial stress syndrome  pain and tenderness over soleus bridgepain and tenderness over soleus bridge  pain with exercise which can progress to otherpain with exercise which can progress to other activitiesactivities  pain increased by hyperpronation of the footpain increased by hyperpronation of the foot Compression neuropathiesCompression neuropathies--  electromyographyelectromyography
    13. 13. Clinical DiagnosisClinical Diagnosis Intracompartmental pressure recordingsIntracompartmental pressure recordings (Taken pre/post exercise w/ slit catheter under local(Taken pre/post exercise w/ slit catheter under local anesthesia)anesthesia) Measurement Pressure Pre-exercise > 15 mm Hg 1 min Post-exercise > 30 mm Hg 5 min Post-exercise > 20 mm Hg Pedowitz et al.Pedowitz et al.
    14. 14. Treating ECSTreating ECS Conservative at firstConservative at first  Cross training with low impact activitiesCross training with low impact activities (swimming, bicycling)(swimming, bicycling)  Rest, Ice, ElevationRest, Ice, Elevation No CompressionNo Compression  NSAIDSNSAIDS  StretchingStretching  Address biomechanical problemsAddress biomechanical problems  Gradual return to activityGradual return to activity
    15. 15. Treatment OptionsTreatment Options If symptoms persist with activity for > 3 toIf symptoms persist with activity for > 3 to 6 months6 months  A: Stop prevocational activitiesA: Stop prevocational activities  B: Have Surgery:B: Have Surgery: Fasciotomy of all involvedFasciotomy of all involved compartmentscompartments
    16. 16. Surgical OutcomeSurgical Outcome Dependent upon compartment involvementDependent upon compartment involvement  Results of anterior and lateral releases areResults of anterior and lateral releases are superior to posterior releasesuperior to posterior release  Failure of Deep posterior compartmentFailure of Deep posterior compartment release largely due to insufficient release-release largely due to insufficient release- as it is harder to get toas it is harder to get to  Management of fasciotomy wounds isManagement of fasciotomy wounds is controversialcontroversial
    17. 17. Outcomesof Fasciotomies in CECS Good/Excellent Study Results (%) Criteria for Results Froneck et al. (1987) 92 Pain, exercise tolerance Detmer et al. (1985) 90 Pain, exercise tolerance Rorabeck et al. (1988) 88 Pain, exercise tolerance * Styf (1987) 90 Free of all symptoms Abramowitz and Schepsis (1994) 77 Free of all symptoms # * All failures were deep posterior compartment # Seven of eight failures were deep posterior
    18. 18. PT Intervention Post SurgeryPT Intervention Post Surgery Immediate Ice and ElevationImmediate Ice and Elevation Crutches (TTWB) with gradual progression toCrutches (TTWB) with gradual progression to FWB (1 week)FWB (1 week) Gait training to prevent abnormal movementGait training to prevent abnormal movement secondary to stiffness and guardingsecondary to stiffness and guarding ROM exercises to increase circulation:ROM exercises to increase circulation:  ankle dorsiflexion, plantar flexion, inversion,ankle dorsiflexion, plantar flexion, inversion, eversion, alphabet exerciseeversion, alphabet exercise  knee flexion/ extensionknee flexion/ extension
    19. 19. Rehab ProgressionRehab Progression Gentle isokineticsGentle isokinetics Stretching, of involved musclesStretching, of involved muscles Aerobic training: Limited WBAerobic training: Limited WB (swimming/cycling)(swimming/cycling) 4 weeks:4 weeks:  progression to running and resistiveprogression to running and resistive weight training as toleratedweight training as tolerated 2-3 months full return to training2-3 months full return to training
    20. 20. ConclusionConclusion Exercise induced ECS is often miss-Exercise induced ECS is often miss- diagnosed.diagnosed. Awareness is key due to the dangers ofAwareness is key due to the dangers of untreateduntreated acuteacute ECS.ECS. Non-surgical interventionsNon-surgical interventions notnot shown toshown to help long term.help long term. Surgery is intervention for reliably highSurgery is intervention for reliably high prognosis.prognosis. PT plays important role in Dx and postPT plays important role in Dx and post surgical Tx.surgical Tx.
    21. 21. QUESTIONS?QUESTIONS?
    22. 22. REFERENCESREFERENCES 1.1. Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes.Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes. British Journal of Surgery.British Journal of Surgery. 2002; 89(4): 397-412.2002; 89(4): 397-412. 2.2. McQueen MM, Gaston P, Court-Brown CM. Acute compartmentMcQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk?[comment].syndrome. Who is at risk?[comment]. Journal of Bone & Joint Surgery - BritishJournal of Bone & Joint Surgery - British Volume.Volume. 2000;82(2):200-203.2000;82(2):200-203. 3.3. Pearse MF, Harry L, Nanchahal J. Acute compartment syndrome of thePearse MF, Harry L, Nanchahal J. Acute compartment syndrome of the leg: fasciotomies must be performed early, but good surgical technique isleg: fasciotomies must be performed early, but good surgical technique is important.important. British Medical Journal.British Medical Journal. 14 September 2002 2002;Volume14 September 2002 2002;Volume 325(7364):557-558.325(7364):557-558. 4.4. Garcia-Mata S, Hidalgo-Ovejero A, Martinez-Grande M. Chronic exertionalGarcia-Mata S, Hidalgo-Ovejero A, Martinez-Grande M. Chronic exertional compartment syndrome of the legs in adolescents.compartment syndrome of the legs in adolescents. Journal of PediatricJournal of Pediatric Orthopedics.Orthopedics. 2001;21(3):328-334.2001;21(3):328-334. 5.5. Prentice WE, Voight MI.Prentice WE, Voight MI. Techniques in musculoskeletal rehabilitationTechniques in musculoskeletal rehabilitation.. New York: McGraw-Hill; 2001.New York: McGraw-Hill; 2001. 6.6. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg:Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder?are clinical findings predictive of the disorder? Journal of Orthopaedic Trauma.Journal of Orthopaedic Trauma. 2002;16(8):572-577.2002;16(8):572-577. 7.7. Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome:Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome: course after delayed fasciotomy.course after delayed fasciotomy. Journal of Trauma-Injury Infection & CriticalJournal of Trauma-Injury Infection & Critical Care.Care. 1996;40(3):342-344.1996;40(3):342-344.

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