Orthopaedic Jobs

Chronic and Exertional Compartment Syndromes



- Anterior Compartment Syndrome:
    - anterior compartment of leg is involved most often; 
    - pain is often burning in nature which worsens with activity and completely subsides after 15 minutes of activity cessation;
    - diff dx:
          - tibial and fibular stress frx;
          - shin splints
          - popliteal artery aneurysm
    - exam:
          - variable weakness of toe extension;
          - pain on passive toe flexion;
          - diminished sensation in the first web space;
    - references:
          - Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy.
          - Management of chronic exertional anterior compartment syndrome of the lower extremity.

- Posterior Compartment Syndrome: (see posterior compartment)
    - exam:
          - weakness of toe flexion and ankle inversion;
          - pain on passive toe extension (may referr to the back of the leg)
          - diminished sensation over the sole of the foot;
    - reference:
          - The tibialis posterior muscle compartment. An unrecognized cause of exertional compartment syndrome.  

- Lateral Compartment Syndrome:
    - signs and symptoms are similar to those of anterior tibial compartment syndrome, but peroneus longus and brevis muscles are involved;
    - pain is usually absent anteriorly, but muscles of the anterior compartment are paralyzed from ischemia of the deep peroneal nerve as it passes through  
           lateral compartment;
    - at surgery, necrosis of peroneus longus & brevis muscles is found, but muscles of anterior compartment appear normal;

- Exam:
    - note presence of any fascial defects;
    - standard motor, sensory, and vascular exam;
    - anterior compartment:
          - variable weakness of toe extension;
          - pain on passive toe flexion;
          - diminished sensation in the first web space;
    - posterior compartment:
          - weakness of toe flexion and ankle inversion;
          - pain on passive toe extension (may referr to the back of the leg)
          - diminished sensation over the sole of the foot;

- Non Operative Treatment:
    - othotics with a medial wedge can be helpful in posterior compartment syndrome, but might make an anterior compartment syndrome worse;

- Indications for Surgery: (see compartment pressure measurement)
    - resting pressure as well as dynamic pressure studies should be performed to give the surgeon pressure profile of the patient;
    - normal compartment pressures at rest are between 0 and 4 mm Hg;
          - some say < 11 mm is normal;
    - postexercise reading of greater than of 35 mm Hg is highly indicative of compartment syndrome & greater than 40 mm Hg is diagnostic;
    - diagnostic threshold is > 15 mm Hg at rest & > 20 mm Hg at 5 minutes after exercise;
    - references:
          Chronic exercise-induced compartment pressure elevation measured with a miniaturized fluid pressure monitor.  A laboratory and clinical study
          Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg
          Intracompartmental pressure increase on exertion in patients with chronic compartment syndrome in the leg.

- Technique: (chronic anterior compartment syndrome)
    - see: fasciotomy of the leg;
    - decompression of anterior & lateral compartments through subQ fasciotomy;
    - use two vertical incisions (one distal and one proximal) centered over anterior intermuscular septum is preferred;
    - if a fascial hernia is present, consider incorporating the fascial defect into the fasciotomy incision;
          - often, the superficial peroneal nerve exits at the site of the hernia;
    - intermuscular septum is identified;
    - fasciotomies are made 1 cm in front & 1 cm behind intermuscular septum;
    - take care to identify and preserve terminal branch of deep peroneal nerve;
    - for chronic posterior compartment syndromes, posteromedial subQ fasciotomy is favored to protect saphenous vein and nerve;
          - in this patient group, it is also necessary to identify tibialis posterior muscle belly and to decompress this muscle as well;
    - once fascial defect is made it should never be repaired, because, after repair, acute compartment syndrome can ensue, w/ catastrophic consequence;
    - references: 
          Chronic anterior-compartment syndrome of the leg. Results of treatment by fasciotomy.
          The results of fasciotomy in the management of chronic exertional compartment syndrome



Chronic leg pain in athletes due to a recurrent compartment syndrome.  

Chronic exercised induced compartment pressure elevation measured with miniaturized fluid pressure monitor



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, August 7, 2012 12:34 pm