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Musculoskeletal System ORGAN SYSTEMS

Chronic exertional compartment syndrome (CECS)

Characterized by a reversible increase in pressure within an inelastic fascial compartment leading to compromised tissue perfusion and subsequent pain and neurologic symptoms.

Introduction

Characterized by a reversible increase in pressure within an inelastic fascial compartment leading to compromised tissue perfusion and subsequent pain and neurologic symptoms.

History:

The earliest account of CECS is documented by Edward Wilson in 1912 who described his symptoms during an Antarctic expedition. French and Price were the first to correlate symptoms with documented increased intracompartment pressures in the British Medical Journal. Mavor recorded the first surgical treatment of CECS in the Journal of Bone and Joint Surgery in 1956 when he described bilateral leg surgery on a soccer player who suffered leg pain from chronic exertion.


Classification

CompartmentSyndromeGraphic2

Aetiology

Lower-extremity CECS (M/C):

  • Running athletes and marching military members

Upper-extremity CECS (rare):

  • Rowers and professional motorcyclists

Pathoanatomy

4 compartments of leg:

  1. Anterior compartment (M/C): Tibialis anterior, extensor digitorum longus, extensor hallucis longus and peroneus tertius.
  2. Posterior superficial comparment: Gastrosoleus complex.
  3. Lateral compartment: Peroneus longus and brevis..
  4. Posterior deep compartment: Tibialis posterior, flexor hallucis longus and flexor digitorum longus.
nihms-774733-f0001
Cross-section of the lower leg depicting the 4 compartments and select key structures | Essentials of Vascular Surgery for the General Surgeon, eds. Gahtan V and Costanza MJ, 2014©, Compartment Syndrome, Bowyer MW, figures 4.5 and 4.7, pgs. 55-69
  • Lower-extremity CECS: Bilateral presentation (80-90% cases)
    • Anterior compartment (40-60%)
    • Lateral compartment (12-35%)
    • Deep posterior compartment (32-60%)
    • Superficial posterior compartment (2-20%)

Clinical features

Symptoms of CECS are secondary to decreased blood flow due to increased compartment pressures.

  • Severe pain
    • Symptoms relieved within minutes to hours of stopping the aggravating activity
    • No history of trauma or direct injury
  • Paresthesia, numbness, and even transient nerve palsy (eg. foot drop)
chronic-exertional-compartment-syndrome
The Calgary Guide | http://calgaryguide.ucalgary.ca/

Diagnosis

Intracompartmental pressures (GOLD STANDARD):

  • Resting intra-compartmental pressure > 15 mmHg
  • Devices:
    • Stryker Intracompartmental Pressure Monitor System
    • Arterial line manometer
    • Whitesides apparatus

Differential diagnosis:

  • Medial Tibial Stress Syndrome (MTSS) “shin splints”:
    • Periostitis of the postero-medial border of the tibia causing pain exacerbated by activity and partially relieved with rest with diffuse tenderness of the postero-medial border of tibia
  • Stress fracture
    • Presents as pain over the tibia/fibula with daily activity and relieved by rest with point tenderness over tibia/fibula, exacerbated by percussion
  • Fascial defects
    • Asymptomatic but symptoms can result from muscle herniation through fascia resulting in nerve compression (M/C over anterior and lateral compartments) causing pain radiating to the dorsum of the foot with muscle bulging.
  • Nerve entrapment syndromes
    • Lateral leg pain elicited by resistance to dorsiflexion and eversion of the ankle and a positive Tinel’s sign
  • Popliteal artery entrapment syndrome (PAES)
    • Artery compression in compartment following chronic exercise causing exertional calf pain with diminished dorsalis pedis pulse with passive plantar flexion or active dorsiflexion
  • Claudication:
    • Poor arterial supply causing leg pain with certain amount of activity and with leg elevation, relieved by rest and dependent leg positioning

Management

Conservative management (not effective):

  • Rest
  • Cessation of problematic activity or decreasing intensity of training
  • Ice packs
  • Physiotherapy

Fasciotomy (mainstay)

  • Techniques:
    • Two-incision technique (leg)
    • Long single lateral incision (thigh) (medial compartment is only rarely involved)
    • volar Henry approach (forearm)
    • Four-incision technique (hand)
  • Complications:
    • Haemorrhage, infection, nerve damage, DVT, vascular injury, skin breakdown, altered sensation over the fasciotomy site, lymphocele, and nerve entrapment
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Lateral fasciotomy wound temporary coverage with negative pressure wound therapy. | Shadgan, B., Menon, M., Sanders, D., Berry, G., Martin, C., Jr, Duffy, P., … O’Brien, P. J. (2010). Current thinking about acute compartment syndrome of the lower extremity. Canadian journal of surgery. Journal canadien de chirurgie, 53(5), 329–334.

Endoscopy-assisted compartment release (pediatric cases)

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