Search

Case: A 22-year-old man with a type IIIA open AO/OTA 61C2.2b pelvis fracture and hypotension received exploratory laparotomy, temporary open ligation of the bilateral internal iliac arteries, and retroperitoneal packing. After prompt fracture debridement, a pelvic binder was positioned over the thighs as a reduction aid and maintained for six hours during pelvis open reduction internal fixation. Bilateral anterior thigh compartment syndrome was diagnosed three hours after packing and binder removal., Conclusion: Prolonged application of a pelvic binder to the thighs as an intraoperative reduction tool, shortly after temporary internal iliac artery ligation, may be associated with reperfusion injury and thigh compartment syndrome., (© 2024. The Author(s).)

This is a case of a 26-year-old active duty male with a 1-year history of distal anterolateral leg pain and numbness which would persist following activity cessation. He was referred to physical therapy and eventually orthopedic surgery for bilateral anterior exertional compartment syndrome and underwent bilateral anterolateral fasciotomies. One year after surgery, he continued to have pain along the posterior aspect of his lower legs with residual numbness over his left dorsomedial foot. He was referred to sports medicine for further evaluation and Botox injections without significant symptomatic changes. He subsequently underwent diagnostic ultrasound of his lower legs which showed multiple entrapment points of the left superficial peroneal nerve along the fasciotomy scar. An additional electrodiagnostic study showed left superficial peroneal sensory mononeuropathy. Eighteen months following surgery, he received his first perineural injection therapy (PIT) treatment. A mixture of lidocaine and D5W was prepared to achieve 1 mg/cc which was then injected along his tibial, saphenous, and sural nerves. Following four PIT sessions, the patient's overall lower extremity pain, weakness, and functionality had improved. This case demonstrates potential benefit with PIT in patients with refractory symptoms following surgery for chronic exertional compartment syndrome. These symptoms may be due to chronic irritation of cutaneous nerves and they may benefit from treatment with PIT. Our case may represent a possible paradigm shift in the conservative treatment of chronic exertional compartment syndrome, especially when refractory to surgical compartment release., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Case: A 26-year-old man presented to the emergency department with atraumatic right leg pain after a period of low-impact activity. He was discharged and returned 3 days later with findings of acute compartment syndrome., Conclusion: We present a case of delayed diagnosis of acute exertional compartment syndrome (AECS) in the setting of rhabdomyolysis, leading to detrimental sequelae. Practitioners with a high degree of clinical suspicion can make a prompt and accurate diagnosis by physical examination alone, allowing early treatment of AECS.

The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.

Background: Patients with Chronic Exertional Compartment Syndrome (CECS) have exercise-limiting pain that subsides at rest. Diagnosis is confirmed by intramuscular compartment pressure (IMCP) measurement. Accompanying CECS, subjective changes to gait (foot slap) are frequently reported by patients. This has not previously been investigated. The aim of this study was to investigate differences in barefoot plantar pressure (BFPP) between CECS cases and asymptomatic controls prior to the onset of painful symptoms., Methods: 40 male military volunteers, 20 with symptoms of CECS and 20 asymptomatic controls were studied. Alternative diagnoses were excluded with rigorous inclusion criteria, magnetic resonance imaging and dynamic IMCP measurement. BFPP was measured during walking and marching. Data were analysed for: Stance Time (ST); foot progression angle (FPA); centre of force; plantarflexion rate after heel strike (IFFC-time); the distribution of pressure under the heel; and, the ratio between inner and outer metatarsal loading. Correlation coefficients of each variable with speed and leg length were calculated followed by ANCOVA or t-test. Receiver operating characteristic (ROC) curves were constructed for IFFC-time., Results: Caseshad shorter ST and IFFC-times than controls. FPA was inversely related to walking speed (WS) in controls only. The area under the ROC curve for IFFC-time ranged from 0.746 (95%CI: 0.636-0.87) to 0.773 (95%CI: 0.671-0.875) representing 'fair predictive validity'., Conclusion: Patients with CECS have an increased speed of ankle plantarflexion after heel strike that precedes the onset of painful symptoms likely resulting from a mechanical disadvantage of Tibialis Anterior. These findings provide further insight into the pathophysiology of CECS and support further investigation of this non-invasive diagnostic. The predictive value of IFFC-time in the diagnosis of CECS is comparable to post-exercise IMCP but falls short of dynamic IMCP measured during painful symptoms., (Copyright © 2018. Published by Elsevier B.V.)

BACKGROUND Acute compartment syndrome (ACS) of the thigh after elective primary total knee arthroplasty is rare. If not recognized and treated promptly, devastating consequences may result. Certain regional anesthesia techniques are thought to mask the symptoms of acute compartment syndrome, but there are no cases reported of adductor canal catheters masking the symptoms of thigh compartment syndrome. We report a case where symptoms and diagnosis of acute anterior thigh compartment syndrome were not masked by a functioning adductor canal catheter. CASE REPORT A 56-year-old male developed anterior thigh compartment syndrome after an elective primary total knee arthroplasty. Surgery was performed under spinal anesthesia with periarticular local infiltration analgesia. Postoperatively, an adductor canal catheter was placed, atraumatically, under ultrasound guidance in the recovery room with a plan to begin a continuous infusion of 0.2% ropivacaine 10 hours after the periarticular injection. Six hours after surgery, the patient complained of tightness and 10/10 pain in his right thigh, which was initially managed with parenteral opioids with moderate success. Continuous infusion through the adductor canal catheter was started and pain improved to 6/10 aching pain. Nonetheless, two hours after starting the continuous infusion, the patient reported tightness, swelling, and 10/10 pressure-like pain that was not relieved by the peripheral catheter infusion or PRN boluses of additional opioids. Due to the patient's symptomatology compartment pressures were measured. The anterior compartment pressure was 47 mm Hg and emergent anterior compartment fasciotomy was performed. CONCLUSIONS In this case, a functioning adductor canal catheter did not mask symptoms of, or delay diagnosis of, acute compartment syndrome in the thigh.

Background: Acute compartment syndrome (ACS) is the result of increased intracompartmental pressure (ICP), and to avoid a delay in diagnosis requires ICP measurement. This study was designed to compare 2 available methods with Bland-Altman analysis for measuring ICP in experimental animal models, healthy volunteers, and patients with suspected ACS to evaluate their agreement and interchangeability., Methods: In 20 New Zealand White rabbits, we inflated a tourniquet to stop arterial blood flow to establish ACS rabbit models, of which ICP was measured and recorded by the Whitesides apparatus and the invasive arterial blood pressure monitor system (IABPMS) before and after modeling. The same 2 measurements were applied to the tibialis anterior compartment's ICP of 30 healthy volunteers. The experimental data were analyzed using the Bland-Altman method. Once it was considered to be a substitute for the Whitesides apparatus based on statistical analysis, we used IABPMS to measure the ICP of the patients suspected of having ACS to estimate its clinical prospect., Results: The rabbit models' ICP estimated by the Whitesides apparatus and IABPMS were 9.60±2.74 and 9.55±2.33 mm Hg, with an increase to 30.20±4.44 and 30.05±4.58 mm Hg after modeling, respectively. The limits of agreement for the ICP were -2.01/2.11 and -2.41/2.71 mm Hg before and after model establishment. The healthy volunteers' ICP were 10.92±6.06 and 10.85±5.87 mm Hg; the limits of agreement for the ICP were -2.53/2.66 mm Hg. With IABPMS to continuously monitor the ICP increasing (40.45±10.42 vs 13.82±4.94 mm Hg) and ΔP (34.54±11.77 mm Hg) to guide the diagnosis of ACS, 5 of 11 patients underwent the emergency fasciotomy for decompression., Conclusion: The invasive pressure monitoring via IABPMS can be used as an alternative to the Whitesides method, thanks to the sufficient agreement between the 2 methods in ICP measurement, and also for its advantages recommended as a novel diagnostic approach to ACS in experimental and clinical applications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Chronic exertional compartment syndrome of the leg is a debilitating lower extremity condition in which increased intracompartmental pressure impedes blood flow to the involved compartments of the distal lower extremity, resulting in ischemia and pain. Owing to the lack of success with conservative management, most surgeons perform complete release fasciotomy as the preferred method of fasciotomy to avoid an unsuccessful release or outcome. Studies have been performed regarding the outcomes of complete compartmental release versus specific compartmental release, but no study has been performed comparing complete fasciotomy and compartment-specific fasciotomy in a single patient. The purpose of the present case report was to compare the efficacy of a complete fasciotomy versus a specific fasciotomy in 1 patient with properly diagnosed bilateral anterior compartment chronic exertional compartment syndrome with an 18-month follow-up period. The Lower Extremity Functional Scale and both subscales of the Foot and Ankle Ability Measure were administered to assess the functional outcomes. Circumferential measurements and range of motion photographs were taken to compare the objective data throughout the recovery process. In general, the range of motion, circumferential measurements, and functional outcome measure scores were better for the specific compartmental fasciotomy leg than for the complete fasciotomy leg during the recovery period. The overall functional outcomes were the same for both surgical approaches, with the specific fasciotomy leg returning to baseline function 13 to 23 days before the complete fasciotomy leg. The outcomes remained unchanged 18 months after surgery., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Compartment syndrome (CS) is a potentially devastating injury associated with tibial fractures. Few data exist regarding radiographic indicators of CS. We hypothesized that radiographic signs are associated with development of CS., Design: Retrospective review., Setting: Level I trauma center., Patients: Consecutive series of adult patients with tibial fractures with (n = 56) and without (n = 922) CS., Intervention: None., Outcomes: AO/OTA fracture classification, Schatzker type, fracture length, fibular fracture, CS diagnosis., Results: The odds of CS increased by 1.67 per 10% increase in the ratio of fracture length to tibial length when considering all fractures. CS was most likely to occur with plateau fractures at 12% (shaft fractures, 3%; pilon fractures, 2%). Schatzker VI fractures were more likely to develop CS than any other Schatzker type. Fibular fracture was predictive of CS with plateau fractures only. Segmental fractures (AO/OTA type 42-C2) were not more likely to develop CS than other shaft fractures., Conclusions: Several objective and easily reproducible radiographic indicators should raise suspicion for CS. CS was more likely in plateau fractures, especially when fracture length was >20% of the tibial length, in the presence of fibular fracture, and classified as Schatzker VI. Conversely, segmental tibial shaft fractures were not more likely than other shaft fractures to develop CS., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: We test a novel simulated teaching module's ability to educate junior residents in the assessment of compartment syndrome (CS) and compartment pressure measurement (CPM)., Methods: Twenty-two postgraduate year 1 and postgraduate year 2 surgical residents received a 2-hour didactic and practical teaching module on CS assessment and CPM using a simulated model. A structured teaching session by a postgraduate year 5 surgical resident was assessed by carefully constructed pretest, post-test, and delayed retention tests and a practical testing session by 2 board-certified general surgeons., Results: Analysis of variance demonstrated significant difference between pretest (6.1/10), post-test (7.9/10), and retention test (8.2/10) scores [F (2,49) = 9.24, P < .01], with no difference in post-test to retention test comparison (P = .90). Mean CPM scores were 8.5/10 for preparation, 9.0/10 for performance, and 8.5/10 for management components, which did not differ [F (2,57) = .46, P = .63]., Conclusions: We demonstrate an efficient simulated CS and CPM teaching module for the education of junior surgical residents using a synthetic model., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Near-infrared spectroscopy measures muscle oxygen saturation (StO2) in the skeletal muscle and has been proposed as a noninvasive tool for diagnosing chronic anterior compartment syndrome (CACS). The purpose of this study was to investigate the diagnostic value of changes in StO2 during and after exercise in patients with CACS., Methods: The study comprised 159 consecutive patients with exercise-induced leg pain. Near-infrared spectroscopy was used to measure StO2 continuously before, during, and after an exercise test. One minute post-exercise, intramuscular pressure was recorded in the same muscle. The cohort was divided into patients with CACS (n = 87) and patients without CACS (n = 72) according to the CACS diagnostic criteria. Reoxygenation at rest after exercise was calculated as the time period required for the level of muscular StO2 to reach 50% (T50), 90% (T90), and 100% (T100) of the baseline value., Results: The lowest level of StO2 during exercise was 1% (range, 1% to 36%) in the patients with CACS and 3% (range, 1% to 54%) in the patients without CACS. The sensitivity was 34% and the specificity was 43% when an StO2 level of ≤8% at peak exercise was used to indicate CACS. The sensitivity and the specificity were only 1% when an StO2 level of ≤50% at peak exercise was used to indicate CACS. The time period for reoxygenation was seven seconds (range, one to forty-three seconds) at T50, twenty-eight seconds (range, seven to seventy-seven seconds) at T90, and forty-two seconds (range, seven to 200 seconds) at T100 in the patients with CACS and ten seconds (range, one to forty-nine seconds) at T50, thirty-two seconds (range, four to 138 seconds) at T90, and forty-eight seconds (range, four to 180 seconds) at T100 in the patients without CACS. When thirty seconds or more at T90 was set as the cutoff value for a prolonged time for reoxygenation, indicating a diagnosis of CACS, the sensitivity was 38% and the specificity was 50%., Conclusions: Changes in muscle oxygen saturation during and after an exercise test that elicits leg pain cannot be used to distinguish between patients with CACS and patients with other causes of exercise-induced leg pain., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: We sought to examine the occurrence of acute compartment syndrome (ACS) in the cohort of patients with tibial diaphyseal fractures and to detect associated risk factors that could predict this occurrence., Materials and Methods: A total of 1,125 patients with tibial diaphyseal fractures that were treated in our centre were included into this retrospective cohort study. All patients were treated with surgical fixation. Among them some were complicated by ACS of the leg. Age, gender, year and mechanism of injury, injury severity score (ISS), fracture characteristics and classifications and the type of fixation, as well as ACS characteristics in affected patients were studied., Results: Of the cohort of patients 772 (69 %) were male (mean age 39.60 ± 15.97 years) and the rest were women (mean age 45.08 ± 19.04 years). ACS of the leg occurred in 87 (7.73 %) of all tibial diaphyseal fractures. The mean age of those patients that developed ACS (33.08 ± 12.8) was significantly lower than those who did not develop it (42.01 ± 17.3, P < 0.001). No significant difference in incidence of ACS was found in open versus closed fractures, between anatomic sites and following IM nailing (P = 0.67). Increasing pain was the most common symptom in 71 % of cases with ACS., Conclusions: We found that younger patients are definitely at a significantly higher risk of ACS following acute tibial diaphyseal fractures. Male gender, open fracture and IM nailing were not risk factors for ACS of the leg associated with tibial diaphyseal fractures in adults., Level of Evidence: Level IV.

We report a case of bilateral anterolateral crural compartment syndrome elicited by hyponatraemia and psychogenic polydipsia. The unusual constellation of clinical findings and diminished pain expression made initial diagnostic procedures challenging. The possible pathogenesis and treatment options are discussed. Impairment of lower extremity function at follow-up was serious and permanent., (2015 BMJ Publishing Group Ltd.)

Background: Patients with chronic exertional compartment syndrome (CECS) have pain during exercise that subsides with rest. Diagnosis is usually confirmed by intramuscular compartment pressure (IMCP) measurement. Controversy exists regarding the accuracy of existing diagnostic criteria., Purpose: (1) To compare dynamic IMCP measurement and anthropometric factors between patients with CECS and asymptomatic controls and (2) to establish the diagnostic utility of dynamic IMCP measurement., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: A total of 40 men aged 21 to 40 years were included in the study: 20 with symptoms of CECS of the anterior compartment and 20 asymptomatic controls. Diagnoses other than CECS were excluded with rigorous inclusion criteria and magnetic resonance imaging. The IMCP was measured continuously before, during, and after participants exercised on a treadmill, wearing identical footwear and carrying a 15-kg load., Results: Pain experienced by study subjects increased incrementally as the study progressed (P < .001). Pain levels experienced by the case group during each phase of the exercise were significantly different (P = .021). Subjects had higher IMCP immediately upon standing at rest compared with controls (23.8 mm Hg [controls] vs 35.5 mm Hg [subjects]; P = .006). This relationship persisted throughout the exercise protocol, with the greatest difference corresponding to the period of maximal tolerable pain (68.7 mm Hg [controls] vs 114 mm Hg [subjects]; P < .001). Sensitivity and specificity were consistently higher than the existing criteria with improved diagnostic value (sensitivity = 63%, specificity = 95%; likelihood ratio = 12.5 [95% CI, 3.2-49])., Conclusion: Anterior compartment IMCP is elevated immediately upon standing at rest in subjects with CECS. In patients with symptoms consistent with CECS, diagnostic utility of IMCP measurement is improved when measured continuously during exercise. A cutoff of 105 mm Hg in phase 2 provides better diagnostic accuracy than do the Pedowitz criteria of 30 mm Hg and 20 mm Hg at 1 and 5 minutes after exercise, respectively., (© 2014 The Author(s).)

The idiomuscular response to direct percussion is rarely tested nowadays because of its uncertain mechanism and significance. While performing neurological examination, we observed a brisk ankle dorsiflexion response on direct muscle percussion of m. tibialis anterior in patients with acute inflammatory demyelinating polyradiculoneuropathy (AIDP). In contrast, in patients with upper motor neuron lesions, an ankle inversion response was seen. In this article we describe our findings in patients with bilateral lower limb weakness. We assessed 73 consecutive patients with bilateral lower limb weakness. A strong dorsiflexion response to percussion of m. tibialis anterior was seen in 11 out of 14 patients with AIDP (sensitivity 78.6%). None of the other patients showed a strong dorsiflexion response (specificity 100%). An inversion response was seen in 11 out of 13 patients with UMN involvement (sensitivity 92.3%). It was also noted in two of 46 patients without proven UMN involvement (specificity 96.7%). The idiomuscular response to percussion of m. tibialis anterior can be useful in the assessment of patients with lower limb weakness of unclear cause.

Background: Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier wants to continue training, there is no proven effective nonoperative treatment, and fasciotomy of 1 or more of the lower leg muscle compartments is usually recommended. Our clinical protocol differs from most reported ones in the use of the forefoot rise test to increase pressure and provoke pain and our recommending minimal surgery of the anterior compartment only. We present results of surgery based on our clinical management flowchart., Methods: Patients who had surgery during a 12-year period were reviewed by telephone interview or office examination. Pain was graded from 0 (none) to 4 (unbearable). Preoperative resting and exercise anterior compartment pressures were evaluated in most subjects before and immediately following a repeated weight-bearing forefoot rise test. Surgery was under local anesthesia, limited to the anterior compartment only and percutaneous (excepting muscle hernias). There were 36 patients, mean age 24 years., Results: Of 16 patients who were originally operated unilaterally, 5 patients were later operated on the other side. Mean presurgery resting pressure was 56 mm Hg (40-80 mm Hg) rising to 87 mm Hg (55-150 mm Hg) with exercise. Mean exercise pain score dropped from 2.9 presurgery to 1.3 postsurgery (n = 35, P < .0001). Complications included superficial peroneal nerve injury (3 legs in 3 patients, 1 requiring reoperation)., Conclusion: When we used our clinical management flowchart based on the forefoot rise test, percutaneous fasciotomy of the anterior compartment alone provided good clinical results. Care must be taken to prevent injury to the superficial peroneal nerve in the distal lower leg., Level of Evidence: Level IV, retrospective case series.

Background: Intracompartmental pressure measurements are frequently used in the diagnosis of compartment syndrome, particularly in patients with equivocal or limited physical examination findings. Little clinical work has been done to validate the clinical use of intracompartmental pressures or identify associated false-positive rates. We hypothesized that diagnosis of compartment syndrome based on one-time pressure measurements alone is associated with a high false-positive rate., Methods: Forty-eight consecutive patients with tibial shaft fractures who were not suspected of having compartment syndrome based on physical examinations were prospectively enrolled. Pressure measurements were obtained in all four compartments at a single point in time immediately after induction of anesthesia using a pressure-monitoring device. Preoperative and intraoperative blood pressure measurements were recorded. The same standardized examination was performed by the attending surgeon preoperatively, postoperatively, and during clinical follow-up for 6 months to assess clinical evidence of acute or late compartment syndrome., Results: No clinical evidence of compartment syndrome was observed postoperatively or during follow-up until 6 months after injury. Using the accepted criteria of delta P of 30 mm Hg from preoperative diastolic blood pressure, 35% of cases (n = 16; 95% confidence interval, 21.5-48.5%) met criteria for compartment syndrome. Raising the threshold to delta P of 20 mm Hg reduced the false-positive rate to 24% (n = 11; 95% confidence interval, 11.1-34.9%). Twenty-two percent (n = 10; 95% confidence interval, 9.5-32.5%) exceeded absolute pressure of 45 mm Hg., Conclusion: A 35% false-positive rate was found for the diagnosis of compartment syndrome in patients with tibial shaft fractures who were not thought to have compartment syndrome by using currently accepted criteria for diagnosis based solely on one-time compartment pressure measurements. Our data suggest that reliance on one-time intracompartmental pressure measurements can overestimate the rate of compartment syndrome and raise concern regarding unnecessary fasciotomies., Level of Evidence: Diagnostic study, level II.

Background: Compartment syndrome is difficult to diagnose, particularly in patients who are not able to undergo adequate clinical examination. Current methods rely on pressure measurements within the compartment, have high false-positive rates, and do not reliably indicate presence of muscle ischemia. We hypothesized that measurement of intramuscular glucose and oxygen can identify compartment syndrome with high sensitivity and specificity., Methods: Compartment syndrome was created in 12 anesthetized adult mixed-sex beagles, in the craniolateral compartment of a lower leg, by infusion of lactated Ringer's solution with normal serum concentration of glucose. The contralateral leg served as a control. Hydrostatic pressure, oxygen tension, and glucose concentration were recorded with commercially available probes. Compartment syndrome was maintained for 8 hours, and the animals were recovered. Two weeks later, compartment and control legs underwent muscle biopsy. Specimens were reviewed by a blinded pathologist., Results: Within 15 minutes of creating compartment syndrome, glucose concentration and oxygen tension in the experimental limb were significantly lower than in the control limb (glucose, p = 0.02; oxygen, p = 0.007; two-tailed t test). Intramuscular glucose concentration of less than 97 mg/dL was 100% sensitive (95% confidence interval [CI], 73-100%) and 75% specific (95% CI, 40-94%) for the presence of compartment syndrome. Partial pressure of oxygen less than 30 mm Hg was 100% sensitive (95% CI, 72-100%) and 100% specific (95% CI, 69-100%) for the presence of compartment syndrome. Pathology confirmed compartment syndrome in all experimental limbs., Conclusion: Our results show that intramuscular glucose concentration and partial pressure of oxygen rapidly identify muscle ischemia with high sensitivity and specificity after experimentally created compartment syndrome in this animal model.

Objective: To compare the intramuscular pressure (IMP) of the tibialis anterior in healthy persons under several exercise conditions with the IMP diagnostic criteria in use for diagnosing chronic exertional compartment syndrome (CECS)., Data Sources: A search of MEDLINE for the period 1966 to March 2010 used the words "intramuscular," "intracompartment," "anterior compartment," and "anterior tibial compartment" linked with "pressure." Reference lists of relevant studies were searched for further articles., Study Selection: Articles published in English that tested IMP in the tibialis anterior in asymptomatic humans were included if they used no interventions before or during IMP testing. Studies were excluded if data were given as a percentage of IMP or if the data could not be extracted for the tibialis anterior compartment alone. From 515 articles identified, 38 studies met selection criteria, Data Extraction: : Details of the studies included IMP measurement technique, timing of measurement (before, during, and/or after exercise), type and duration of exercise, the number of compartments measured, and participants' ages. Mean or median pressure was recorded in mm Hg., Diagnostic Standard: Criteria for the upper limit of normal pressure under different conditions were the Pedowitz criterion for preexercise IMP (15 mm Hg), the Puranen criterion for IMP during exercise (50 mm Hg), the Styf criterion for relaxation pressure (30-55 mm Hg), and the Pedowitz criteria for mean 1-minute postexercise and 5-minutes postexercise pressures (30 mm Hg and 50 mm Hg, respectively)., Main Results: Exercise was mostly treadmill walking/running (duration, 1.5-120 min) or ankle dorsiflexion (duration, 10 sec-20 min). Methods of measuring IMP varied from study to study. The lowest mean IMP was identified preexercise at rest (range, 0-20 mm Hg). Five of the 34 studies found a higher mean resting pressure than the criterion (15 mm Hg). Mean pressure during exercise (10 studies, 9 of running, with durations of 5-20 min) varied between 23 mm Hg and 66 mm Hg. Two of these studies found a higher mean peak pressure during exercise than the criterion (50 mm Hg). Mean relaxation IMP, measured in 9 studies, was approximately 25 mm Hg in the 1 treadmill study in which it was measured, whereas studies of dorsiflexion found a range of approximately 5 to 15 mm Hg. All the studies found lower mean relaxation IMP than the criterion (35-50 mm Hg). One of 11 studies and 1 of 10 studies found the mean postexercise IMP after 1 minute and 5 minutes to be above the criteria of 30 mm Hg and 20 mm Hg, respectively., Conclusions: The limits of anterior tibialis IMP before, during, and after exercise that are used as diagnostic criteria for CECS would include many asymptomatic persons. Intramuscular pressure values were not valid criteria for the presence of the syndrome.

Acute compartment syndrome is a time-sensitive diagnosis and surgical emergency because it poses a threat to life and the limbs. It is defined by Matsen et al (Surg Gynecol Obstet. 1978;147(6):943–949) as "a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space." The most common cause of compartment syndrome is traumatic injury. A variety of other conditions such as vascular injuries, bleeding disorders, thrombosis, fasciitis, gas gangrene, rhabdomyolysis, prolonged limb compression, cellulitis, and nephrotic syndrome may also cause compartment syndrome. Patients who are elderly, have preexisting nerve damage, or have psychopathology may have an atypical presentation. This case highlights the first report of a 75-year-old woman who developed painless bilateral compartment syndrome in the absence of traumatic injury.

The aim of this study was to present a case of iatrogenic thromboembolectomy-related tibialis anterior false aneurysm (FA) treated with endovascular FA exclusion and anterior leg compartment (ALC) operative decompression and to assess the current management options in posttraumatic leg vessel FAs. A 68-year-old man had a painful pulsating mass in the superior ALC 2 months after a thromboembolectomy was performed during popliteal aneurysm repair. He had been discharged under oral anticoagulation and had ALC manual massages for mild post-revascularization leg edema. Angio-CT showed tibialis anterior injury successfully treated with a covered stent graft, while a residual ALC hematoma was surgically evacuated. Endovascular treatment of tibialis anterior FAs using a covered stent graft is an excellent therapeutic option. After an endovascular procedure, caution must be taken to identify the need for early operative ALC decompression. Current leg vessel FA management should consider both the specific anatomic characteristics of the FA and the possibility of development of delayed compartment syndrome., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Fresh human cadavers provide an effective model for procedural training. Currently, there are no realistic models to teach fascial compartment pressure measurement., Objectives: We created a human cadaver fascial compartment pressure measurement model and studied its feasibility with a pre-post design., Methods: Three faculty members, following instructions from a common procedure textbook, used a standard handheld intra-compartment pressure monitor (Stryker(®), Kalamazoo, MI) to measure baseline pressures ("unembalmed") in the anterior, lateral, deep posterior, and superficial posterior compartments of the lower legs of a fresh human cadaver. The right femoral artery was then identified by superficial dissection, cannulated distally towards the lower leg, and connected to a standard embalming machine. After a 5-min infusion, the same three faculty members re-measured pressures ("embalmed") of the same compartments on the cannulated right leg. Unembalmed and embalmed readings for each compartment, and baseline readings for each leg, were compared using a two-sided paired t-test., Results: The mean baseline compartment pressures did not differ between the right and left legs. Using the embalming machine, compartment pressure readings increased significantly over baseline for three of four fascial compartments; all in mm Hg (±SD): anterior from 40 (±9) to 143 (±44) (p = 0.08); lateral from 22 (±2.5) to 160 (±4.3) (p < 0.01); deep posterior from 34 (±7.9) to 161 (±15) (p < 0.01); superficial posterior from 33 (±0) to 140 (±13) (p < 0.01)., Conclusion: We created a novel and measurable fascial compartment pressure measurement model in a fresh human cadaver using a standard embalming machine. Set-up is minimal and the model can be incorporated into teaching curricula., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To describe the characteristic presentation of exertional leg pain in athletes and to discuss the diagnostic options and surgical management of exertional anterior compartment syndrome of the leg in this group of patients., Methods: Data from a series of athletes presenting with exertional leg pain were analysed and categorized according to aetiology., Results: Sixty-six athletes presenting with exertional leg pain in 102 limbs were analysed. Sixteen patients in a first group of 20 patients with a provisional diagnosis of exertional anterior compartment syndrome of the leg underwent a closed fasciotomy with complete resolution of symptoms. A second group of 42 patients were diagnosed as medial tibial stress syndrome and a third group of four patients had confirmed stress fracture of the tibia., Conclusion: Exertional leg pain is a common presenting complaint of athletes to sports physicians and physiotherapists. Careful analysis can lead to an accurate diagnosis and commencement of effective treatment. Exertional anterior compartment syndrome can be successfully treated utilizing a closed fasciotomy with a rapid return to sport.

Acute compartment syndrome (ACS) of the thigh is an uncommon condition usually treated surgically by emergency dermofasciotomy. We report a rare case of acute delayed compartment syndrome of the anterior compartment of the thigh following an uncemented Total Hip Replacement (THR). Surgical decompression was performed and patient had full recovery.

Background: The aim of our study was to document the estimated sensitivity and specificity of continuous intracompartmental pressure monitoring for the diagnosis of acute compartment syndrome., Methods: From our prospective trauma database, we identified all patients who had sustained a tibial diaphyseal fracture over a ten-year period. A retrospective analysis of 1184 patients was performed to record and analyze the documented use of continuous intracompartmental pressure monitoring and the use of fasciotomy. A diagnosis of acute compartment syndrome was made if there was escape of muscles at fasciotomy and/or color change in the muscles or muscle necrosis intraoperatively. A diagnosis of acute compartment syndrome was considered incorrect if it was possible to close the fasciotomy wounds primarily at forty-eight hours. The absence of acute compartment syndrome was confirmed by the absence of neurological abnormality or contracture at the time of the latest follow-up., Results: Of 979 monitored patients identified, 850 fit the inclusion criteria with a mean age of thirty-eight years (range, twelve to ninety-four years), and 598 (70.4%) were male (p < 0.001). A total of 152 patients (17.9%) underwent fasciotomy for the treatment of acute compartment syndrome: 141 had acute compartment syndrome (true positives), six did not have it (false positives), and five underwent fasciotomy despite having a normal differential pressure reading, with subsequent operative findings consistent with acute compartment syndrome (false negatives). Of the 698 patients (82.1%) who did not undergo fasciotomy, 689 had no evidence of any late sequelae of acute compartment syndrome (true negatives) at a mean follow-up time of fifty-nine weeks. The estimated sensitivity of intracompartmental pressure monitoring for suspected acute compartment syndrome was 94%, with an estimated specificity of 98%, an estimated positive predictive value of 93%, and an estimated negative predictive value of 99%., Conclusions: The estimated sensitivity and specificity of continuous intracompartmental pressure monitoring for the diagnosis of acute compartment syndrome following tibial diaphyseal fracture are high; continuous intracompartmental pressure monitoring should be considered for patients at risk for acute compartment syndrome.

We report a case of anterior thigh compartment syndrome, which occurred after man's thigh was bruised after flipping repeatedly over his bike and being hit by the frame of the bike nearly at around 6 pm. The next day at 1:30 am, he was admitted to the hospital. The initial presentation was a hematoma, and the patient was kept in bed with local cooling. The compartment syndrome of the thigh (CST) diagnosis was made around 6:00 pm when the level of pain was interpreted as disproportionate to the treated lesion; anterior compartment pressure measure was 84 mmHg. A compartment fasciotomy was performed. It is difficult to diagnose a CST in case of muscular contusion as the latter causes symptoms that are similar to CST. A conservative treatment without fasciotomy was carried out by several authors, especially in sportsmen showing a CST following contusion. This conservative treatment implies close monitoring of intramuscular pressures and adjuvant measures (bed rest, holding the thigh at the heart level and oxygenotherapy).

Chronic exertional compartment syndrome (CECS) of the lower limb is part of a group of overuse lower limb injuries with common presenting features. It is commonly diagnosed by the measurement of raised intramuscular pressures in the lower limb. The pathophysiology of the condition is poorly understood, and the criteria used to make the diagnosis are based on small sample sizes of symptomatic patients. We carried out a systematic review to compare intramuscular pressures in the anterior compartment of healthy subjects with commonly used criteria for CECS. Thirty-eight studies were included. With the exception of relaxation pressure, the current criteria for diagnosing CECS, considered to be the gold standard, overlap the range found in normal healthy subjects. Several studies reported mean pressures that would prompt a positive diagnosis for CECS, despite none of the subjects reporting any symptoms. The intramuscular pressure at all time points has also shown to vary in relation to a number of other factors other than the presence of CECS. Taken together, these data have major implications on the ability to use these published criteria for diagnosis and question the underlying pathophysiology. Clinicians are recommended to use protocol-specific upper confidence limits to guide the diagnosis following a failed conservative management., (© 2011 Crown Copyright.)

Objective: Although all intracompartmental pressure (ICP) measurement, magnetic resonance imaging, and near-infrared spectroscopy seem to be useful in confirming the diagnosis of chronic exertional compartment syndrome (CECS), no standard diagnostic procedure is currently universally accepted. We reviewed systematically the relevant published evidence on diagnostic criteria commonly in use for CECS to address 3 main questions: (1) Is there a standard diagnostic method available? (2) What ICP threshold criteria should be used for diagnosing CECS? (3) What are the criteria and options for surgical management? Finally, we made statements on the strength of each diagnostic criterion of ICP based on a rigorous standardized process., Data Sources: We searched for studies that investigated ICP measurements in diagnosing CECS in the leg of human subjects, using PubMed, Score, PEDRO, Cochrane, Scopus, SportDiscus, Web of Knowledge, and Google Scholar. Initial searches were performed using the phrase, "chronic exertional compartment syndrome." The phrase "compartment syndrome" was then combined, using Boolean connectors ("OR" and "AND") with the words "diagnosis," "parameters," "levels," "localisation," or "measurement." Data extracted from each study included study design, number of subjects, number of controls, ICP instrument used, compartments measured, limb position during measurements, catheter position, exercise protocol, timing of measurements, mean resting compartment pressures, mean maximal compartment pressures, mean postexercise compartment pressures, diagnostic criteria used, and whether a reference diagnostic standard was used. The quality of studies was assessed based on the approach used by the American Academy of Orthopaedic Surgeons in judging the quality of diagnostic studies, and recommendations were made regarding each ICP diagnostic criteria in the literature by taking into account the quality and quantity of the available studies proposing each criterion., Main Results: In the review, 32 studies were included. The studies varied in the ICP measurement techniques used; the most commonly measured compartment was the anterior muscle compartment, and the exercise protocol varied between running, walking, and ankle plantarflexion and dorsiflexion exercises. Preexercise, mean values ranged from 7.4 to 50.8 mm Hg for CECS patients, and 5.7 to 12 mm Hg in controls; measurements during exercise showed mean pressure readings ranging from 42 to 150 mm Hg in patients and 28 to 141 mm Hg in controls. No overlap between subjects and controls in mean ICP measurements was found at the 1-minute postexercise timing interval only showing values ranging from 34 to 55.4 mm Hg and 9 to 19 mm Hg in CECS patients and controls, respectively. The quality of the studies was generally not high, and we found the evidence for commonly used ICP criteria in diagnosing CECS to be weak., Conclusions: Studies in which an independent, blinded comparison is made with a valid reference standard among consecutive patients are yet to be undertaken. There should also be an agreed ICP test protocol for diagnosing CECS because the variability here contributes to the large differences in ICP measurements and hence diagnostic thresholds between studies. Current ICP pressure criteria for CECS diagnosis are therefore unreliable, and emphasis should remain on good history. However, clinicians may consider measurements taken at 1 minute after exercise because mean levels at this timing interval only did not overlap between subjects and controls in the studies we analyzed. Levels above the highest reported value for controls here (27.5 mm Hg) along with a good history, should be regarded as highly suggestive of CECS. It is evident that to achieve an objective recommendation for ICP threshold there is a need to set up a multi-center study group to reach an agreed testing protocol and modify the preliminary recommendations we have made.

Background: Anterior compartment syndrome (ACS) and rhabdomyolysis are rare complications of hypothyroid myopathy. We report the case of a young man with rapid onset of ACS who presented with simultaneous primary hypothyroidism and adrenal insufficiency associated with acute renal failure, hyponatremia, and hyperkalemia., Patient Findings: A 22-year-old man presenting with a one-month history of tiredness, hyperpigmentation, and cramps in his calves was found to have severe bilateral foot drop. Investigations revealed severe primary hypothyroidism and adrenal insufficiency, renal failure, and evidence of rhabdomyolysis with myoglobinuria. Abnormal biochemical findings included serum sodium of 110 mM, serum potassium of 6.9 mM, and serum creatine kinase (CK) of >25,000 IU/L. Magnetic resonance imaging (MRI) of his legs showed changes of myonecrosis confined to anterior tibial muscles typical of ACS. After treatment with intravenous fluids, potassium-lowering therapies, thyroxine, and hydrocortisone, his renal and metabolic function returned to normal, but irreversible bilateral foot drop persisted., Summary: A young man with primary hypothyroidism, adrenal insufficiency, hyponatremia, and hyperkalemia presented with severe myopathy, such that muscle necrosis, apparently confined to the anterior tibial compartment on MRI, led to rhabdomyolysis, acute renal failure, and irreversible bilateral peroneal nerve damage. It is possible that other patients with primary hypothyroidism and marked elevations of CK without widespread myopathy or rhabdomyolysis may demonstrate evidence of differential muscle effects in the anterior compartment when assessed by MRI, but that this patient also had adrenal insufficiency raises the possibility that this was a contributing factor., Conclusions: Severe thyroid myopathy and rhabdomyolysis may be associated with anatomic susceptibility to ACS, particularly in the presence of concomitant adrenal insufficiency. MRI examination reveals a distinctive appearance of myonecrosis confined to the anterior compartment.

Compartment syndrome of the thigh is a rare emergency often treated operatively. The purpose of this study was to evaluate the effects of nonoperative treatment for compartment syndrome of the thigh associated with acute renal failure after the 2008 Wenchuan earthquake. Nonoperative treatment, which primarily involves continuous renal replacement therapy, was performed in 6 patients (3 men and 3 women) who presented with compartment syndrome of the thigh associated with acute renal failure. The mean mangled extremity severity score (MESS) and laboratory data regarding renal function were analyzed before and after treatment, and the clinical outcome was evaluated at 17-month follow-up. Laboratory data regarding renal function showed improvements. All 6 patients survived with the affected lower limbs intact after nonoperative treatment. Follow-up revealed active knee range of motion and increased muscle strength, as well as a recovery of sensation. A positive linear correlation was found between MESS and the time required to achieve a reduction in swelling, as well as the time required for the recovery of sensation and knee range of motion (r>0.8; P<.05). Satisfactory clinical outcomes were obtained in patients with compartment syndrome of the thigh associated with acute renal failure.Urine alkalization, electrolyte and water balance, and continuous renal replacement therapy have played an important role in saving lives and extremities. Nonoperative treatment should be considered in the treatment of compartment syndrome of the thigh associated with acute renal failure., (Copyright 2012, SLACK Incorporated.)

Despite more recent non-invasive modalities generating some credence in the literature, intracompartmental pressure testing is still considered the 'gold standard' for investigating chronic exertional compartment syndrome (CECS). Intracompartmental pressure testing, when used correctly, has been shown to be accurate and reliable. However, it is a user-dependent investigation, and the manner in which the investigation is conducted plays a large role in the outcome of the test. Despite this, a standard, reproducible protocol for intracompartmental pressure testing has not been described. This results in confusion regarding interpretation of results and reduces the tests' reliability. A summary of the current understanding of CECS is presented, along with the results of a survey of specialists in Australia and New Zealand who perform intracompartmental pressure testing, which confirms that a uniform approach is currently not used in clinical practice. This highlights the need for a consensus and standardised approach to intracompartmental pressure testing.

Acute traumatic compartment syndrome of the foot is a serious potential complication after fractures, crush injuries, or reperfusion injury after vascular repair. Foot compartment syndrome in association with injuries to the ankle is rare. This article presents a case of acute compartment syndrome of the foot following open reduction and internal fixation of an ankle fracture. A 16-year-old girl presented after sustaining a left ankle injury. Radiographs demonstrated a length-stable posterior and lateral malleolar ankle fracture. Initial treatment consisted of a bulky splint and crutches pending the improvement of her swelling. Over the course of a week, the soft tissue environment of the distal lower extremity improved, and the patient underwent open reduction and internal fixation of both her fibula and distal tibia through 2 approaches. Approximately 2 hours from the completion of surgery, the patient reported worsening pain over the medial aspect of her foot and into her calcaneus. Physical examination of the foot demonstrated a swollen and tense abductor hallicus and heel pad. Posterior tibial and dorsalis pedis pulses were palpable and her sensation was intact throughout her foot. Emergently, fasciotomy of both compartments was performed through a medial incision. Postoperatively, the patient reported immediate pain relief. At 18-month follow-up, she reported no pain and had returned to all of her preinjury athletic activities., (Copyright 2010, SLACK Incorporated.)

Compartment syndrome involves a conflicting situation between an unyielding space, the compartment, and its increasing tissue content secondary to traumatic ischemia. Rapidly irreversible damages occur without treatment. Although the diagnosis approach to leg compartment syndrome is clinical in priority, pressure measurements should be systematically produced: first to confirm the presence of this condition and define optimal surgical strategies and second to provide the only objective available criteria in case of a debatable diagnosis. In practice, two schematic situations can be distinguished, which do not cover the many different cases: leg compartment syndrome without a fracture in which the four leg compartments are affected and which requires a fasciotomy using two surgical approaches, the lateral and the medial; leg compartment syndrome associated with a fracture: fasciotomy of the four compartments may be performed by a single lateral approach distant from the fracture site and its fixation hardware. It should be noted that this approach is easy, effective and safe., (Copyright © 2010. Published by Elsevier Masson SAS.)

Chronic exertional compartment syndrome should be considered in any runner experiencing exertional leg pain. Runners typically describe a tight, cramping ache over the involved compartment that commences at a reproducible point in the run and resolves with rest. Diagnosis should include a careful history and physical examination as well as documentation with intramuscular compartment pressure monitoring. Milder cases will resolve with activity modification and conservative care. More severe cases or those failing conservative care are referred for fasciotomy., (Copyright 2010. Published by Elsevier Inc.)

This article presents a case of a patient with popliteal artery occlusion following anterior and posterior instrumented fusion of the lumbar spine. No previous study has reported acute anterior tibial compartment syndrome due to popliteal artery occlusion and restricted venous return following spine surgery. A 53-year old female, with a twice failed fusion of L5-S1, underwent L3-S1 anterior interbody and posterior L3-S1 instrumented fusion. Due to postoperative continuous analgesia, the patient was sleepy and confused on postoperative day 1. On the postoperative day 2, the right calf and anterolateral tibia manifested clinical signs of compartment syndrome and both thighs exhibited pressure ecchymoses from the antiembolism stockings. Fasciotomies of the right tibial compartments were undertaken and necrosis of the anterior compartment muscles was found. Intraoperative arteriogram revealed occlusion of the right popliteal artery and thrombectomy was performed. Lupus anticoagulant was found to be responsible for patient's coagulopathy. During postoperative year 1, the patient still had weakness and recurrent edema of the right foot. Unrecognized limb ischemia and possibly restricted venous return were the causes of the compartment syndrome. Surgeons should be aware of this devastating complication of spine surgery., (Copyright 2010, SLACK Incorporated.)

Lower limb compartment syndrome following coronary artery bypass surgery is a rare complication that is easily overlooked. Here we report a case of lower limb compartment syndrome that was diagnosed and treated promptly in a 53-year-old man, thereby preventing a potentially lethal outcome.