Perineural Injection Therapy for Chronic Exertional Compartment Syndrome Refractory to Initial Compartment Release: A Case Report.

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.

Compartment syndrome of the leg after thyroid hormone withdrawal; two cases and a systematic review of the literature.

BACKGROUND: Acute compartment syndrome is a rare complication of severe hypothyroidism. If the symptoms are not recognized promptly and treatment initiated immediately, there is a high risk of permanent damage. Only few other cases of compartment syndrome due to hypothyroidism have been published and the exact pathophysiological mechanism remains unknown. CASE PRESENTATIONS: A 59 year old male developed acute compartment syndrome of his right lower leg after thyroid hormone withdrawal prior to radioiodine remnant ablation after total thyroidectomy for follicular thyroid cancer. He underwent emergency fasciotomy of all four compartments of the lower leg. The muscle tissue in the anterior and lateral compartment was necrotic and was therefore excised. The second patient was a 62 year old female with Hashimoto's thyroiditis, who developed acute compartment syndrome of both lower legs after thyroid hormone withdrawal due to non-compliance. Emergency fasciotomy of all four compartments of both legs was performed. The muscle tissue was viable in all compartments. CONCLUSION: Although compartment syndrome due to hypothyroidism is uncommon, it is a complication physicians should be aware of. The majority of reported cases are caused by an acute withdrawal of thyroid hormones and not by undetected hypothyroidism. No previous case of compartment syndrome caused by an iatrogenic hormone withdrawal in preparation for radioactive iodine has been published. However, as shown in this report, it may be beneficial to inform patients of this rare complication prior to hormone withdrawal in preparation for remnant ablation after thyroidectomy.

Is external fixation needed for the treatment of tibial fractures with acute compartment syndrome?

Acute compartment syndrome (ACS) after tibial fracture carries a risk of various complications, including infection, delayed union, nonunion, nerve damage, and poor prognosis. For the treatment of fractures with ACS, fasciotomy is conducted, and the method to stabilise the fracture has to be considered. Thirty-five patients who underwent surgery for ACS with tibial shaft fractures were evaluated, and the results of initial internal fixation (Group I, 20 patients) and initial external fixation (Group II, 15 patients) were analysed. The mean age was 41 years. Five patients needed additional surgery for bone union. Complications occurred in 4 cases, but no deep infection was reported. The time to bone union, the need for additional surgery, and the incidence of complications in Group I and Group II were not statistically different. For the treatment of ACS with tibial fracture, immediate internal fixation and changing from external fixation to internal fixation did not affect the clinical course.

Well-leg compartment syndrome after laparoscopic low anterior resection for lower rectal cancer in the lithotomy position: A case report.

A 64-year-old man underwent laparoscopic low anterior resection for lower rectal cancer. Because he was overweight (BMI, 28.1 kg/m2 ) with rich visceral fat and a narrow pelvic cavity, the operation was technically difficult and the operation time was 686 min. Postoperatively, the patient immediately complained of pain and swelling of the left lower limb. Laboratory examination showed that serum creatinine kinase was markedly increased and urine myoglobin was positive on postoperative day 1. He was diagnosed with well-leg compartment syndrome and was transported to the trauma and critical care center for emergency fasciotomy. After initial treatment, he was transferred to our hospital on postoperative day 7. He completely recovered after 2 months. Although well-leg compartment syndrome is rare, it is necessary to consider it as a potential complication when performing a long colorectal cancer surgery with the patient in the lithotomy position, particularly when laparoscopic surgery is planned.

Muscle Microvascular Blood Flow, Oxygenation, pH, and Perfusion Pressure Decrease in Simulated Acute Compartment Syndrome.

BACKGROUND: The current gold standard for diagnosing acute compartment syndrome (ACS) is an assessment of clinical signs, invasive measurement of intramuscular pressure (IMP), and measurement of local perfusion pressure. However, IMP measurements have several shortcomings, including pain, risk of infection, risk of technique error, plugging of the catheter tip, lack of consensus on the diagnostic pressure threshold, and lack of specificity and sensitivity. The objective of this study was to evaluate muscle hemodynamics, oxygenation, and pH as diagnostic parameters in a human model of ACS. We hypothesized that as IMP increases, muscle microvascular blood flow, oxygenation, and pH decrease in the anterior compartment of a leg at heart level and that they decrease significantly more when the leg is elevated further. METHODS: An external pneumatic leg pressure chamber, combined with a venous stasis thigh cuff, was used to increase IMP and simulate ACS. Eight healthy subjects (5 males and 3 females; mean age, 26 years) had photoplethysmography and near-infrared spectroscopy-pH sensors placed over the middle aspect of the tibialis anterior muscle of the right (experimental) and left (control) legs. Leg chamber pressure conditions (40, 50, and 60 mm Hg) were applied in a randomized order after baseline measurements were taken. Data were collected continuously for each 11-minute pressure condition, with an 11-minute recovery period after each condition, and the average of the last 6 minutes was used for data analyses. The same protocol was repeated with each subject's legs elevated 12 cm above heart level. Data were analyzed using repeated-measures analysis of variance (ANOVA). RESULTS: As IMP increased, muscle microvascular blood flow (p = 0.01), oxygenation (p < 0.001), and pH (p < 0.001) all decreased significantly in the experimental leg compared with the control leg. At all IMP levels, leg elevation significantly decreased muscle oxygenation (p = 0.013) and perfusion pressure (p = 0.03) compared with the control leg at heart level. CONCLUSIONS: These results indicate that muscle microvascular blood flow, oxygenation, pH, and perfusion pressure decrease significantly as IMP increases in a human model of ACS. CLINICAL RELEVANCE: This study identifies hemodynamic and metabolic parameters as potential noninvasive diagnostic tools for ACS.

Lower Extremity Compartment Syndrome After Coronary Artery Bypass: Easy to Miss Unless Suspected.

Acute compartment syndrome after coronary artery bypass grafting (CABG) is a rare adverse event, and the diagnosis is challenging unless this condition is actively considered. We report a case from our institution of a patient with confounding presentation leading to a delayed diagnosis of compartment syndrome after CABG.

Do one-time intracompartmental pressure measurements have a high false-positive rate in diagnosing compartment syndrome?

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.

The thickness of the anterior compartment does not indicate compartment syndrome in acutely traumatised legs?

BACKGROUND: The study was conducted to achieve early detection of increased compartment pressure by comparing the changes between the thickness and pressure within the musculofascial compartments after lower leg injury. METHODS: We included cases of a lower-leg fracture between January and December 2007. Bilateral lower leg compartment pressure and thickness were measured before the surgery and post-anaesthesia, and the surgery was performed within 12 h after the initial trauma. The intracompartment pressure (ICP) was measured with a Wick catheter pressure monitor. The thickness (width) of the anterior compartment of lower leg was measured using ultrasound. RESULTS: All data were measured within 4-6h of the injury. The average thickness in injured legs versus uninjured was 30 mm (15-46 mm) versus 20.4 mm (13-30 mm), P<0.001. The average intracompartment pressure (ICP) in injured leg versus uninjured was 45.3 mmHg (26-80 mmHg) versus 17.5 mmHg (15-20 mmHg), P<0.001. The thickness and ICP were significantly increased for injured lower legs compared to the uninjured legs, but the increase in ICP did not show a significant relationship with the change in thickness of the injured lower leg. CONCLUSION: In this study, the results of ICP and thickness changes of injury lower leg compared with uninjured leg revealed no statistically significant correlation. Some injuries showed a high ICP with only mild changes in thickness, while some showed a high ICP with significant changes. Although ultrasound has many advantages for the evaluation of soft tissue changes after trauma, this study revealed that thickness changes are not a predicable parameter for determining pressure on the acute fracture of lower leg.

Unicompartment compartment syndrome following laparascopic colonic resection.

We report the case of a 43-year-old man who developed anterior compartment syndrome following laparoscopic colorectal surgery in the lithotomy position. This was initially masked by postoperative epidural usage and ultimately diagnosed 2 days postoperatively. The patient underwent decompression by four compartment fasciotomy and two follow-up re-explorations of the affected lower limb. This case is unique for two reasons: only the anterior compartment of the lower limb was affected--which is rare in itself--and there was a delay in presentation secondary to postoperative epidural usage.

Surgical management of exertional anterior compartment syndrome of the leg / Tratamiento quirúrgico del síndrome compartimental anterior de la pierna por esfuerzo excesivo

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.

OBJETIVO: Describir las manifestaciones características del dolor en la pierna que presentan los atletas, y discutir las opciones de diagnósticos y tratamiento quirúrgico del síndrome compartimental de la pierna en este grupo de pacientes. MÉTODOS: Los datos de una serie de atletas con dolor en la pierna debido al esfuerzo excesivo en los ejercicios, fueron analizados y categorizados según la etiología. RESULTADOS: Sesenta y seis atletas con dolor de piernas debido al esfuerzo excesivo en 102 miembros fueron analizados. Dieciséis pacientes en un primer grupo de 20 pacientes con un diagnóstico provisional de síndrome compartimental anterior de la pierna por esfuerzo experimentaron fasciotomía cerrada con resolución completa de los síntomas. Un segundo grupo de 42 pacientes fueron diagnosticados con síndrome de estrés medial de la tibia, y a un tercer grupo de cuatro pacientes se le confirmó fractura por estrés o sobrecarga de la tibia. CONCLUSIÓN: El dolor de la pierna por esfuerzo en los ejercicios es una queja común con las que los acuden a los médicos y fisioterapeutas de la medicina deportiva. Un análisis cuidadoso puede conducir a un diagnóstico preciso y al comienzo de un tratamiento eficaz. El síndrome compartimental anterior por esfuerzo puede tratarse con éxito utilizando una fasciotomía cerrada que permita un rápido retorno a la actividad deportiva.

Endovascular exclusion coupled with operative anterior leg compartment decompression in a case of postthromboembolectomy tibialis anterior false aneurysm.

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.

The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome.

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.

Compartment syndrome of the thigh after blunt trauma: a complication not to be ignored.

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).

Anterior thigh compartment syndrome after prone positioning for lumbosacral fixation.

We report a case of a patient who developed anterior thigh compartment syndrome after being positioned prone for instrumented lumbar spine surgery. Although rare, clinicians should be aware that compartment syndrome is a possible complication of spinal surgery.

Acute compartment syndrome of the foot following fixation of a pilon variant ankle fracture.

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.

Bilateral anterior compartment syndrome after routine coronary artery bypass surgery and severe hypothyroidism.

Compartment syndrome is a very rare complication of coronary artery bypass grafting and previously it has only been described unilaterally. We describe the development of compartment syndrome in bilateral anterior compartments of the lower leg after vein harvest for coronary artery bypass grafting. We describe a series of predisposing factors contributing to this condition and its delayed diagnosis, including severe undiagnosed hypothyroidism. We advise a high index of suspicion in patients postvein harvest and recommend thyroid function testing for all patients who have compartment syndrome develop.

Acute tibial compartment syndrome following spine surgery.

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.

Lower limb compartment syndrome following coronary artery bypass surgery: a rare entity.

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.