PRESENTOR: DR THOUSEEF A MAJEED

1. ANTERIOR TIBIAL SYNDROME
&
REYNAUDS DISEASE
MODERATOR:
PROF .DR.K.PRAKASAM
M.S Ortho, D.Ortho, DSc (HON)
Director & HOD

2. ANTERIOR TIBIAL
SYNDROME

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.

6. Pathogenesis
Unaccustomed exercise
Muscle trauma of anterior muscles of leg
Pressure inceases with in the anterior compartment of
leg obstructing venous out flow
Ischaemic necrosis

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.

19. REYNAUDS DISEASE

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

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%

26. SECONDARY REYNAUDS DISEASE
• Due to underlying disease
1. Collagen vascular disease-
Scleroderma
Systemic Lupus Erythramatosis (SLE)
Rheumatoid Arthritis (RA)
Diabetis Mellitus

27. 2. Arterial occlusive disease
• Thromboangitis obliterans
• Acute arterial occlusion
• Thorasic outlet syndrome
4. Neurologic disorders
• Intervertebral disc disease
• Syringomyelia
• Spinal cord tumour
• Stroke

28. 5. Blood dyscrasias
• Cold agglutinins
• Cryoglobulinemias
• Myeloproliferative disorders
• Waldenstrom’s macroglobulinemia

29. 6. Trauma
• Vibration injury
• Electric shock
• Cold injury
• Typing
7. Drugs
• Ergot derivatives
• Methyl sergide
• Bleomycin
• Vinblastin
• Cisplatin

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

31. Clinical Features:

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.

33. Differential Diagnosis

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.

36. NOVEL TECHNIQUES…

37. MANAGEMENT

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

42. • Surgery:
– Cervico dorsal sympathectomy

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,

44. THANK YOU!