Search

Objective: Decompression of all four muscle compartments of the lower leg to normalize tissue pressure and prevent permanent neuromuscular dysfunction., Indications: Incipient compartment syndrome (characterized by excessive pain, muscle pain on extension, tensely swollen and shiny skin, and Δp>30 mmHg without neuromuscular deficit) and no clinical improvement after conservative treatment and/or acute compartment syndrome (symptoms as for incipient compartment syndrome with neuromuscular deficit and Δp<30 mmHg)., Contraindications: None. There is some dispute about indications and timing of fasciotomy and necrectomy when the need for dermatofasciotomy is recognized late (e.g. intubated intensive care patients)., Surgical Technique: In unilateral compartment release as described by Matsen, the lateral compartment is decompressed first through a parafibular approach. After identification of the anterior and superficial posterior compartments by transverse incision of the fasciae, these muscles are also decompressed longitudinally. Finally, the deep posterior compartment beneath the lateral compartment is decompressed. In bilateral dermatofasciotomy, the fasciae of the anterior and lateral compartments are incised through a proximal anterolateral approach and the superficial and deep posterior compartments through a distal dorsomedial approach., Postoperative Management: Synthetic skin substitute or vacuum-assisted wound closure until definitive closure by secondary suture or mesh grafting after about 5 days. Patient mobilization generally depends on the concomitant bone injury., Results: During the period from October 2001 to November 2008, 37 dermatofasciotomies were performed at our hospital to treat acute posttraumatic compartment syndrome. On the day of dismissal, symptoms of neuromuscular dysfunction after acute compartment syndrome had not disappeared completely in 5 patients. One patient received intermittent dialysis for acute kidney failure after crush syndrome. There were perioperative complications in a total of 6 patients: iatrogenic neurotomy (n=1), hematoma requiring revision (n=2), deep wound infection (n=2), and superficial disturbed wound healing (n=1).

Patients suffering from sickle cell disease show an increased ischemic intolerance due to continuous pro-inflammatory activation and dysfunction of the endothelium by recurrent vaso-occlusive episodes. The presented case shows the manifestation of a postoperative compartment syndrome of the lower leg following the intraoperative use of blood arrest in a patient with previously unknown sickle cell disease. Preexisting vulnerability for tissue hypoxia in patients at risk should be a major concern for intraoperative use of blood arrest during surgery of the extremities.

A 30-year-old man presented several times with pain in the calf after twisting his foot and injuring it during bowling. It was some time before the diagnosis of acute exertion-induced compartment syndrome was made, and an immediate fasciotomy could no longer prevent necrosis of the peroneal muscles. Because of the patient's drop-foot, we performed a tibialis posterior tendon transfer, fixing it to the cuneiform bone. The sort of compartment syndrome observed after engagement in various sports is a recognised, albeit uncommon, variant of acute compartment syndrome. A high level of suspicion and observation is required to make the diagnosis when any leg pain has no definite diagnosis. Fasciotomy should be performed early.

Background: Acute compartment syndrome of the leg is to be regarded as a traumatological emergency. Most specialists already agree that only a timely operative decompression of the afflicted compartment can prevent serious tissue damage. What still remains subject to discussion, however, is the precise tissue pressure above which the operation becomes imperative. Experimental human studies focusing on tissue pressure and muscle oxygenation have not yet been carried out. It was thus the aim of the present study to analyze oxygen partial pressure of the anterior tibial muscle and peroneal action potential in a model compartment syndrome in man., Methods: In 22 healthy, normotensive volunteers, constant pressure values from 0 to 100 mmHg were induced in the anterior tibial muscle with antishock trousers. Over a period of up to 6 h measurements were made of (1) tissue pressure, (2) intramuscular oxygen partial pressure (pO2), and (3) muscle response potential (MRP) of the n. peroneus profundus by electroneurography., Results: We achieved a 97.7% (Q25%/Q75%: 89.2/99.8) transfer of the pneumatic pressure to the lower leg. Already at intramuscular tissue pressures of 30-40 mmHg, hypoxia and reduction of MRP appeared. A reduction of the MRP to zero and pO2 < 1 mmHg was observed from a pressure of 50 mmHg. Tissue pressure values of over 75 mmHg resulted almost without exception in anoxia of the muscle., Conclusions: Even under normal perfusion conditions, already slight increases in pressure of above 30 mmHg lead to reduced tissue oxygenation and neural function. We have to consider that with additionally traumatized muscle the ischemic tolerance is markedly reduced and due to unknown influences such as local vasoreactivity and capacity of autoregulation the nutritive perfusion cannot be determined. In the case of a severely injured muscle, to be on the safe side decompressive fasciotomy should therefore be carried out if pressure values remain above 30 mmHg.

Introduction: The chronic exertional compartment syndrome of the musculus tibialis anterior is thought to be responsible for a major part of complaints of the lower leg among active sportsmen. There is an important role of tissue pressure measurement in diagnosing chronic anterior compartment syndrome during muscular activity. However, there is a controversial debate about the relevant parameters., Methods: Metaanalysis of all the 21 studies (1979-1998) measuring intracompartmental pressures during muscular activity. Parameters of analysis: type of exercise, catheter technique, recommendations of diagnostic criteria., Results: Analysis of literature shows that there has been no standardisation concerning the type of muscular exertion (isometrics for 5-10 min, exercise on the treadmill between 3.2 and 12 km/h). In 8 of the 21 studies the results have been attained through the unsuitable Wick-catheter-technique. In the overall view none of the suggested criterions for diagnosis is taken up by other teams. There are considerable variations up to 500% regarding the recommended parameters., Conclusions: From all studies no uniform recommendation for parameters of diagnostic relevance can be derived. On this background it should be demanded that future research is conducted by a uniform regimen for examination and modern technique of measuring with a high temporal resolution. Under these standardised conditions the investigated parameters of the intracompartmental pressure curve should be reconsidered once more regarding diagnostic predictability by calculations of specifity and sensitivity.

In this article we report a case of an early postoperative compartment syndrome of the anterior tibial compartment with complete sensomotoric palsy of the peroneal nerve after arthroscopic-assisted replacement of the anterior cruciate ligament (ACL) of the knee. The tourniquet pressure was 360 mm Hg and operation time was 1.75 h. After the operation the leg was bandaged to avoid swelling of the leg and as antithrombotic prophylaxis. Analgesic therapy was by continuous epidural bupivacaine infusion. Increasing pain of the lower leg was suppressed by additional analgesia. Due to persistent pain despite regular analgesia, the patient was sent to a main hospital on the 3rd postoperative day, where an extremely painful and swollen anterior tibial compartment with intracompartmental pressure of over 100 mm Hg was found. The compartment was released immediately. Despite the appearance of severe muscle damage, no extensive débridement was done. At the second examination, at 48 h, there was minimal perfusion of the muscles without contraction and islands of ischemic necrosis. Clinically, there was complete palsy of the dorsiflexors of the foot. The case shows the danger of a compartment syndrome when tourniquet of the limb, arthroscopy and a firm bandage are combined. Continuous epidural analgesia masks the classic symptoms of compartment syndrome.

The intracompartmental pressure in the anterior tibial compartment was documented under standardized conditions in 29 patients walking at a speed of 4.5 km/h, as well as heel-and-toe running at a speed of 8 km/h. All pressure curves were integrated and the resulting mean pressure was compared with the arithmetic mean pressure indicated in the literature. During walking, the difference between calculated and integrated pressures was between 80 and 140%. In the case of heel-and-toe running, the difference was between 80 and 165%. On the basis of these results, the calculation of the mean intracompartmental pressure recommended in the literature does not appear to be of any clinical relevance.

The compartment syndrome is a common complication in the traumatology of the lower limb. In vascular surgery it is observed following emergency revascularisation. It is a rare condition as an initial symptom of a peripheral clotted aneurysm. By means of a case with a complicated popliteal aneurysm the differential diagnosis of the non-traumatologic compartment syndrome is discussed.

For the purpose of follow-up of the disease as well as the availability of magnetic resonance imaging (MRI) as a method for diagnosing soft tissue changes 20 patients with imminent and manifest compartment syndrome were examined for their fluid content of the lower limb. Considering the normal side as well as 10 healthy volunteers a significant reduction of fluid content was diagnosed in the manifest compartment syndrome after fasciotomy in the late phase of disease (r = 0.49, p > 0.005, n = 29). This was interpreted as a sign of fibrosis. The patients with imminent compartment syndrome and fasciotomy (r = 0.83, p > 0.001, n = 19) demonstrated no significant changes compared to the normal volunteers (r = 0.91, p > 0.001, n = 40) as well as the normal compartments of the diseased lower extremities (r = 0.85, p > 0.001, n = 32). MRI is a useful method in the examination of soft tissue changes and underlines the importance of an early fasciotomy in case of imminent compartment syndrome.

In two young athletic men we made the diagnosis of chronic tibialis anterior syndrome. Pain during strenuous exercise was localized in the anterolateral aspect of both calves. After stopping exercise the complaints disappeared within 15-20 minutes and not in 2-3 minutes as it would be typical for patients with atherosclerotic peripheral arterial occlusive disease. Diagnosis is based on patient history, normal clinical examination (systolic ankle pressure determined by Doppler-Sonography, electronic segmental oscillography) and increased intramuscular pressure at rest (> 10 mmHg) and after exercise (42 and 35 mmHg). Bilateral fasciotomy was performed in both patients. They are free of pain after 3 respectively 6 months postoperatively.

In acute compartmental syndrome, it is difficult to decide on the basis of clinical criteria alone whether fasciotomy is indicated or not. Reliable and objective parameters are required before a treatment schedule can be devised. We tested mechanical impedance as a parameter for the pressure inside the tissue. The technique and associated apparatus for measuring mechanical impedance of the skin overlying the anterolateral compartment of the lower leg are described in detail. We performed the non-invasive measurement in 25 patients with leg injuries. There were 2 patients with acute compartmental syndrome and 5 with imminent compartmental syndrome. In normal legs, the mechanical impedance was between 2 and 6.5 kg/s, with an average of 3.83 kg/s. After the impedance is increased to 10 kg/s or higher, there is acute or imminent compartmental syndrome. Once the compartment has been decompressed by unilateral parafibular fasciotomy, the mechanical impedance decreases to normal values. Clinically relevant results were obtained by this method and they correlated well with the other clinical findings.

Fifty recreational athletes were subjected to a defined exercise programme (running on a treadmill, 8 km/h). The pressure in the middle third of the anterolateral compartment was measured. We also assessed the geometry and the echogenicity in the transversal and the longitudinal plane by sonographic means. The increase of the intracompartmental pressure increased as the ap-diameter of the compartment in the transverse plane increased (distance = superficial fascia - interosseous membrane). We found a correlation factor of 0.79. The echogenicity increased as the intracompartmental pressure increased. The changing ultrasound reflex pattern is considered non-reproducible because there are too many artifacts, nor is the increase in the ap-diameter due to the low correlation.

Two cases are reported of late condition after mild anterior tibial compartment syndrome often seen by orthopaedists, particularly after fracture of the lower leg. Pathophysiology, causes, clinical representation, diagnosis and differential diagnosis, as well as the therapy of this still relatively unknown syndrome are discussed. Simple equipment for measuring the pressure in the compartment is introduced. The importance of early diagnosis is emphasised.

A brief account is given of the aetiology and pathophysiology of the compartmental syndrome. Without decompression, acute compartmental syndrome causes irreversible muscle necrosis after six hours. Immediate diagnosis and therapeutic action are, therefore, imperative. Chronic courses are rare and are, probably, not unambiguously identifiable. Compartmental syndrome of the anterior tibial zone, when misinterpreted and taken for a muscular hernia, may lead to the development of acute compartmental syndrome with all its complications, once the fascia has been closed. Surgical opinion is discussed on the basis of the above case history.

The tibialis anterior syndrome, which is the most frequent so-called compartment syndrome of the lower extremity, is described by means of the pathophysiological processes generally applicable to the compartment syndrome. Both the clinical signs and treatment as well as the diagnosis are given in this article. To extend the differential diagnosis the authors present a woman patient referred to hospital with the pattern of a tibialis anterior syndrome as shown by anamnesis and clinical signs. However, surgery did not reveal any traumatic action as the cause of the tibialis anterior syndrome; instead, the real cause was large lipoma which in our opinion gradually resulted in a pressure increase in the anterior tibial muscle area. The accident which had been considered responsible had in our opinion merely tended to aggravate an already existing condition which would surely have resulted eventually in an intrafascial pressure increase and in the development of a tibialis anterior syndrome pattern even without any trauma. Hence, the pattern of a tibialis anterior syndrome had been caused in this particular case by a space-occupying growth in the area of the anterior tibial muscle, i.e. by a lipoma, Correspondingly, one should always consider when performing differential diagnosis of the tibialis anterior syndrome whether the underlying cause may be a space-occupying growth, such as a tumour.

The anterior tibial syndrome is caused by primary or secondary ischemia of the tibial muscles group. Acute onset of intensive pain, swelling of the muscles and reddening of the skin are the clinical features of the syndrome. The muscles enzymes are raised. The definite diagnosis is established by the typical "silent-EMG". Surgical decompression within 24 hours after onset of the symptoms is of essential prognostic importance.

There is no generally accepted method for compartmental pressure measurement, as yet. Substantial disadvantages are implied in methods based on outflow resistance measurement, and, above all, these methods are hardly suitable for long-time pressure measurement nor for objectivation of dynamic pressure alterations. Described in this paper is the authors' own method, using a wick catheter. It is highly reproducible and is characterised by high measuring dynamics. A comparatively large amount of hardware is required. Evidence is produced to the impact of differentiated conditions of examination on measuring results. Values measured by means of this method in the anterotibial compartment of the lower leg did not normally exceed a pressure level of 2.0 kPa.