pathology: compartment syndrome

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compartment syndrome

Definition of

Condition in which increased tissue pressure leads to a reduction in tissue perfusion when the skin and soft tissue mantle is closed, resulting in neuromuscular disorders or tissue and organ damage due to restrictions or cessation of nutritive microcirculation. The lower leg, forearm and foot are usually affected. There are the following muscle compartments:

  1. Flexor ligament of the thigh (Compartimentum femoris posterius)
  2. Extensor ligament of the thigh (Compartimentum femoris anterius)
  3. Adductor ligament of the thigh (Compartimentum femoris mediale)
  4. Flexor ligament of the lower leg (Compartimentum cruris posterius)
  5. Extensor ligament of the lower leg (Compartimentum cruris anterius)
  6. Fibularis lodge (Compartimentum cruris laterale)

Distinguish between two types of compartments:

  1. Functional/chronic (stress-associated, also: exertional compartment syndrome)
  2. Acute (traumatic, possibly with fractures) or post-op

The functional compartment can be reproduced during training under the same conditions and usually begins with exhaustion of the affected muscles, later a feeling of pressure or cramp, followed by loss of control and even later a creeping numbness.

The most common is anterior compartment syndrome, which affects the tibialis anterior, extensor digitorum longus, extensor hallucis longus and fibularis tertius dorsiflexors (extensors). A shortened or hypertonic triceps surae is predisposed, as is a reduced ability to dorsiflex. The pain occurs at the
anterior lateral edge of the tibia.

It is much rarer to find a deep posterior compartment in the flexor digitorum longus, flexor halluxis longus and tibialis posterior. Here the pain occurs at the medial edge of the tibia or as deep calf pain. If the posterior tibialis has its own sheath,
persistent chronic pain can occur. If paresthesia or weakness of the muscles occurs, this may indicate a nerve bottleneck syndrome caused by the pressure.

ICD T79.6

Cause

  1. Traumas such as fractures, muscle contusions: Increased pressure due to bruising or oedema as a result of violence compresses nerves or vessels, resulting in reduced blood flow, venous congestion leads to a further increase in pressure, which can lead to necrosis
  2. Aortic rupture
  3. Functional compartment: endurance performance from middle distance to triathlon
  4. Burn injury
  5. Ischemia
  6. OP

Predisposing

For a functional compartment, the following factors can be specified as dispositive:

  1. female
  2. Overstriding: placing the foot in front of the body’s center of gravity: long stride length, low stride frequency, greater dorsiflexion and more pronounced eccentric contraction of the foot lifts the anterior compartment
  3. Heel running style: large dorsiflexion angle at foot strike
  4. Incorrect footwear (large drop, i.e. „heel“)
  5. Greater increase in training intensity
  6. Uphill running route (front compartment)

Diagnosis

  1. Palpation
  2. Pressure probe: pressure already increased by 15 mmHg at rest, increased by over 30 mmHg after 1 minute of exercise, still over 20 mmHg 5 minutes after the end of exercise
  3. Stryker measuring device for intracorporeal pressure measurement with extracorporeal probe

Symptoms

  1. Painful, hardened muscles(pain at rest + pain on movement + pain on pressure + pain on stretching)
  2. Analgesic-resistant pain, can also be triggered by passive movement
  3. Spontaneous muscle pain as a sign of ischemia
  4. Tingling, paresthesia
  5. Sensory disorders
  6. Elevation does not improve
  7. Later pulse loss/attenuation distal to the affected area
  8. later motor deficits, paresis

Complications

  1. Hypoxic muscle necrosis with subsequent fibrosis
  2. Paralysis
  3. Loss of the limb
  4. on the forearm: Volkmann’s stiffness
  5. in the case of extensive muscle breakdown (rhabdomyolysis): Circulatory disorders, possibly kidney failure
  6. In extreme cases: MSOF (multiple system organ failure) and death

Therapy

  1. at low pressure: store flat, cool, regular observation, analgesics
  2. For acute, non-functional compartment: dermatofasciotomy (incision in the fascia to relieve pressure) from 30 mmHg
  3. Functional compartment: PECH for as long as necessary, followed by light aerobic training. Fasciotomy in severe cases

DD

  1. Muscle hematoma
  2. Muscle strain
  3. Torn muscle fiber
  4. Muscle cramp
  5. Deep vein thrombosis(phlebothrombosis): distal swelling with tenderness
  6. Infection
  7. Shin splint: shows pain again immediately after a short break in the same training session
  8. Stress fracture
  9. Patellar compression syndrome
  10. Tendinitis: hurts mainly over the tendon itself, less over the muscles
  11. Nerve root compression syndrome
  12. Vascular compression, e.g. popliteal due to pronounced Baker’s cyst