Arm Pump Elimination System Book
Chronic exertional compartment syndrome (CECS) is another cause of athletic lower leg pain. Patients with CECS complain of cramping, burning, or aching lower leg pain with pain or numbness that may radiate to the foot and ankle. The pain is clearly associated with exertion. Pain onset is characteristically at a fixed point in the patient's activity, with progressively increasing pain if the exercise continues and a dramatic reduction in pain within minutes of rest. The pathophysiology of CECS involves elevated intracom-partmental pressure, which causes relative ischemia of the involved muscles and pressure on neurovascular structures. The diagnosis of CECS can be confirmed by compartment pressure testing after exercise demonstrating increased intra-compartmental pressure correlated with symptom reproduction. Patients with CECS should be questioned about the use of nutritional supplements, such as creatine, that may increase muscle water content and overall muscle mass and contribute...
Compartment syndrome of the thigh can also be seen on a rare occasion after extensive workouts or contusion to the anterior thigh.6 Symptoms are similar to those in the leg as outlined later in this chapter, which is more commonly seen. A high index of suspicion is needed when pain out of proportion to any injury is reported. Other signs include paresthesias and severe pain with passive motion or stretch of the muscles in the involved compartment. Treatment includes catheter pressure monitoring and fasciotomies as indicated. Compartment pressures7 of more than 30 mm Hg or within 30 of the diastolic blood pressure have both been used as thresholds for considering compartment fascial releases. The thigh has anterior, posterior, and medial compartments. The anterior and posterior compartments can usually be released from a lateral incision. The medial compartment often does not need to be released, and some surgeons will do the lateral incision, release the anterior and posterior...
This pain syndrome is mainly seen in middle-distance and endurance runners as well as in orienteers. Symptoms appear during and after running and may progress to a chronic compartment syndrome located at the gastrocnemius-soleus muscle complex. Intracompartmental pressure measurements can confirm the diagnosis, and in case of elevated pressure, fasciotomy is the ultimate treatment. The common crural fascia can be opened posteriorly at one or both sides.
Isolated chronic compartment syndrome in the peroneal muscles is rarely seen. But several authors state that when there is an anterior compartment syndrome, the lateral peroneal compartment is simultaneously affected. Therefore standard surgery has been fas-ciotomy of both the anterior and lateral compartments of the leg 6 . The necessity of the strategy has been questioned, and one study 15 has shown that the results after fasciotomy of the anterior compartment alone were as good as when fasciotomy of both compartments were performed.
Chronic anterior compartment syndrome is a typical chronic exertional compartment syndrome. The muscles of the anterior compartment of the leg are involved, causing burning pain in dorsiflexion of the ankle, especially during running, walking and jumping. The compartment is usually painful during palpation and the muscle mass may be hypertrophic. An elevated intracompartmental pressure has been found in several studies, during both rest and exercise 1,6,7,14,15 . It is generally agreed that a pre-exercise pressure of 15 mmHg or more, a i-min postexercise pressure of 30 mmHg or more and a 5-min postexercise pressure of 20 mmHg or more is pathologic and proof of chronic compartmental syndrome i . During exertion the intracompartmental pressure can be higher than 100 mmHg. Some non-invasive tests for the detection of chronic compartmental syndrome have been developed. These include radioisotope scintigraphy associated with emission tomography for regional muscle perfusion defects in the...
Compartment syndrome of the forearm is in most cases post-traumatic, caused by hematoma or edema, and not particularly a sports injury. Very often the person has been lying on the arm for several hours during intoxication by alcohol or medicine. Direct trauma or muscle tears during sports can lead to edema and intracompartmental bleeding and a fulminant compartment syndrome. The symptoms are constant pain and fatigue of the involved muscle group. Clinically the involved muscle group is swollen, hard and very tender, and active function exerts extreme pain. The person should be admitted to hospital as fast as possible for surgical decompression by splitting the Repeated heavy work with the forearm muscles, e.g. in weight-lifting, gradually increases muscle mass, which can cause compartment syndrome, as can acute edema of the muscle after excessive training 60,61 . In the exertional compartment syndrome symptoms appear during activity, e.g. weight-lifting or racquet sports, and they...
The NASG is particularly suited to use in low-resource settings. Lighter and more flexible than the PASG, it is more comfortable for a woman to be inside the suit for longer periods of time, something necessary in the long transport times and delayed treatment conditions of low-resource settings. As with the PASG, within minutes of being placed in the NASG, a patient's vital signs are restored and, if confused or unconscious, their sensorium generally clears1. Women can remain in the NASG for as long as is required to restore their circulatory volume with crystalloids and to replace blood. In prior reports of cases where blood transfusions were not readily available, this has often required 18-24 h, and, in one case, a woman remained safely in the NASG for 57 h23. Compared to the PASG, with pressures of 100 mmHg or more, the NASG only applies 30-40 mmHg. Higher pressures appear to be responsible for skin and muscle ischemia and adverse effects on pH as well as the occasional anterior...
V Anterior compartment syndrome can be caused by a tibial fracture or a high-velocity blow to the anterior compartment of the leg, resulting in increased pressure in the anterior compartment of the leg. Because the fascia covering the anterior compartment is unable to expand, pressure continues to build, causing restricted blood flow and eventual necrosis of tissues. If untreated, anterior compartment syndrome can result in amputation of the limb. Treatment varies in more severe cases, a fasciotomy is performed and the fascia covering the anterior compartment is cut to relieve the pressure.
The periosteal-fascial junction of the soleus muscle and (iii) chronic posterior compartment syndrome. Clement has introduced the term 'posterior tibial syndrome' 2 , characterized by pain and tenderness along the posterior medial aspect of the tibia over the posterior tibialis muscle and tendon.
The multisegmental organization of spinal innervation has an effect on spinal pain therapy because, in the absence of a technique for selectively producing a lesion of the sinuvertebral nerve in the treatment of dorsal compartment or articular facet syndromes, the target structures are the medial branch of the dorsal rami of spinal roots or nerves and, in ventral compartment syndromes, the target structures are the sympathetic chain and the communicating ramus. The dorsal compartment syndrome, or articular facet syndrome, usually presents nonspecific symptoms its diagnosis is therefore based on some common clinical criteria (1) medial and or paravertebral hemi- or bilateral lumbar pain, either continuous or during most of the day (2) absence of neurologic deficits (3) pain on pressure on paravertebral masses and (4) pain on lumbar hyperextension.
Hypovolemia, hypothermia, and associated injuries are the rule and should be treated first. General treatment of immersion foot (or hand) is the same as that for frostbite that has been rewarmed. Swelling may produce compartment syndrome and require fasciotomy. Most patients require admission to the hospital.
When electricity traverses the tissues, it may cause a host of injuries contact burns, thermal injury, arc burns, muscular tetany, or blunt trauma due to severe muscle contraction. Sudden death (asystole, respiratory arrest, ventricular fibrillation), myocardial damage, cerebral edema, neuropathies, disseminated intravascular coagulation, myoglobinuria, compartment syndrome, and various metabolic disorders have been described.
Loading failure at the musculotendinous junction. This muscle spans both the knee and the ankle. It is so named tennis leg because it is commonly encountered in a middle-aged individual during the push-off phase while playing tennis.28 Swelling and sometimes ecchymosis are seen. Seldom is a major defect palpated, but often there may be acute or chronic slight muscle mass loss in that area. Concomitant acute compartment syndrome has been reported.29 As with other muscular strains, the phases of injury, inflammatory healing, and remodeling occur as a rehabilitation course is undertaken. Resolution of symptoms and no significant loss in functional performance are the typical course.
The term 'shin splints' has been used as a general name for overuse injuries of the lower leg, except stress fractures and compartmental syndrome 1,4 . The pain is induced by physical exercise and is located an-terolaterally or medially on the leg. Rather than the diffuse term shin splints, the exact diagnoses of lower leg injuries in athletes with lower leg pain should be used. These include the medial tibial syndrome, anterior, lateral and posterior compartment syndromes, fascial defects, the tennis leg, the popliteal artery entrapment syndrome and effort-induced venous thrombosis in addition to stress fractures (see Table 6.1.1, p. 536).
Appears after a certain amount of exercise, just as vascular claudication. Reduction of activity relieves the symptoms, whereas elevation of the leg makes them worse. The symptoms resemble posterior compartment syndrome, but there are normal intracompart-mental pressures. In physical examination distal pulses can be weak or absent during maximal isometric ankle dorsiflexion and hyperextension of the knee. With non-invasive vascular investigations such as ankle brachial index and Doppler ultrasound the diagnosis can usually be established. However, angiography directly after exercise is the most precise diagnostic investigation.
Table 6.1.1 Characteristics of and differences between tibial stress syndrome, compartment syndrome and stress fractures. Table 6.1.1 Characteristics of and differences between tibial stress syndrome, compartment syndrome and stress fractures. Chronic compartment syndrome
Congenital muscular torticollis is the most common type of torticollis. It presents in the newborn period. Its cause is unknown, but it has been hypothesized to arise from compression of the soft tissues of the neck during delivery, resulting in a compartment syndrome. Radiographs of the cervical spine should be obtained to rule out congenital vertebral anomalies. Clinical examination reveals spasm of the sternocleidomastoid muscle on the same side as the tilt causing the typical posture of head tilt toward the tightened muscle and chin rotation to the opposite side. Initial treatment is stretching and is successful in up to 90 of patients during the first year of life. Surgery is considered for persistent deformity after 1 year of age. Common problems noted in patients with congenital muscular torticollis include congenital hip dysplasia and plagiocephaly (facial asymmetry).
The main dangers of casts are if they are applied incorrectly. A tight cast can act as a constraint and hence cause a kind of iatrogenic compartment syndrome. This is particularly the case shortly after injury, or manipulation, and often a 'backslab' (i.e. a plaster that does not go around the whole circumference of the injured part) is applied.
The incidence of compartment syndrome in the thigh after contusion is not well described, but in rare instances may occur and must then be treated with fas-ciotomy. Most authors advocate a high clinical suspicion for compartment syndrome in limbs where thigh girth fails to stabilize after contusion and recommend compartment pressure monitoring however, no report of anterior thigh compartment release for contusion related compartment syndrome has demonstrated muscle injury at the time of surgery.39 None of the major series describing treatment of quadriceps contusions report any cases of compartment syndrome or the completion of thigh fasciotomies.38-40 In cases in which arterial injury is suspected, fasciotomy should still be considered as a treatment option. Arteriography is a useful study in this unlikely scenario.
1 In a less severe in situ necrosis type of injury only the myofibers are damaged, whereas the basal lamina and the mysial sheaths are not breached. In its mildest form such an injury occurs in eccentric exercise and more extensive in situ necrosis can be caused for example by ischemia as seen in compartment syndrome or after injection of local anesthetic (e.g. bupivacaine). Repair after in situ necrosis can be virtually complete. In more extensive in situ necrosis type of injuries, as in the compartment syndrome, the myofibers become necrotized within their intact basal lamina over a variable length, in the most severe cases the entire length of the myofiber. Both the basal lamina and the connective tissue framework of different mysial sheath remain intact. The satellite cells are remarkably resistant to different types of injury, including ischemia, and they become activated after the insult has subsided and the regeneration process has been initiated. The basal lamina provides the...
Recurrent goiter may arise with symptoms and signs varying from a barely palpable asymptomatic nodule to a large cervi-cothoracic mass causing compartmental syndromes. Clinical presentation is different if patients are diagnosed during a regular follow-up study, in which recurrences are often asymptomatic, or if they come from surgical series, in which more severe symptoms are commonly required. In Berglund's follow-up study,7 only 4 of the 26 recurrences observed required surgery 2 because of suspicion of malignancy and 2 because of compression symptoms. In the remaining 22 patients, recurrences were small and of little clinical significance. On the other hand, in the surgical series of Roeher and Goretzki,15 three quarters of patients complained of severe compressive symptoms (Table 33-1). COMPARTMENTAL SYNDROMES Fibrosis resulting from previous surgery around the recurrent goiter and adjacent structures can cause severe compressive symptoms, even in the absence of a large thyroid...
The reported incidence of peripheral nerve injury is about 1 in every 1000 anaesthetics. Poor positioning is a common underlying factor. The brachial plexus and superficial nerves of the limbs (ulnar, radial and common peroneal) are the most frequently affected nerves. The usual mechanism of injury to superficial nerves is ischaemia from compression of the vasa vasorum by surgical retractors, leg stirrups or contact with other equipment. Nerve injury can be part of a compartment syndrome of a limb after ischaemia from poor positioning. Ischaemic injury is more likely to occur during periods of poor peripheral perfusion associated with hypotension or hypothermia. Nerves can also be injured by traction, e.g. the brachial plexus during excessive shoulder abduction. Needlestick or chemical injury can also occur during regional anaesthesia.
Absolute surgical indications include irreducibility, vascular injury, open injury, compartment syndrome, and inability to maintain reduction with nonoperative methods. When there are no indications for emergent surgical intervention, reduction, immobilization, and MRI can be performed followed by delayed surgical intervention.
Rhabdomyolysis is a disease process whereby damage sustained by the muscle fibers leads to the dissolution of the compromised structural components of the muscle fibers of the involved area. The subsequent elimination of the waste products released can be toxic to the kidneys and can lead to renal failure. Rhabdomyolysis is seen after crushing injuries and contusions but has been reported after extreme overuse episodes such as heavy or maximized weight training. It may be seen as well with compartment syndrome.
The overall outlook for functional return is good, and the risk of myositis ossificans is proportional to the amount of bleeding and degree of the original injury.1 If myositis ossificans becomes a significant factor, range of motion may be more difficult to obtain and the patient may develop a hard mass in that area on a long-term basis. Increased or specialized padding to protect that area for future contact may be appropriate. Excision of myositis ossificans deposits has met with limited success. Compartment syndrome after thigh contusion has been reported, and this entity is discussed later.
According to clinical symptoms and signs described above and confirmation of decreased canal size based on CT scan. MRI is used preoperatively. Myelography is used if more than one level is affected or if patients have scar tissue after previous surgery. It is important to exclude other diagnoses that can produce signs of claudication compartment syndrome, diabetic neuropathy, disk herniation, vascular claudication and tumor.
Fascial defects can be symptomatic in association with chronic compartment syndromes. Increased intra-compartmental pressure may result in herniation of muscle through an attenuated fascial defect i,6 . Reneman 6 observed fascial defects in approximately 60 of patients with chronic compartment syndrome. Usually the herniation occurs in the distal third of the anterolateral leg, often at the fascial opening for the cutaneous branch of the superficial peroneal nerve. Not all fascial defects are symptomatic, though. If there is pain, local tenderness, compression neuropathy or ischemia of herniated muscle tissue, fasciotomy is recommended, avoiding damage to the nerve branches 6,7 . Closure of the defect is contraindicated as it can lead to increased symptoms and, in the worst case, to an acute compartment syndrome.
Colosimo AJ, Ireland ML Thigh compartment syndrome in a football athlete A case report and review of the literature. Med Sci Sports Exerc 1992 24 958-963. 24. Mubarak SJ, Owen CA Double-incision fasciotomy of the leg for decompression in compartment syndromes. J Bone Joint Surg Am 1977 59 184-187. 25. Fronek J, Mubarak SJ, Hargens AR, et al Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop 1987 220 217-227. 26. Pedowitz RA, Hargens AR, Mubarak SJ, et al Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990 18 35-40. 27. Ota Y, Senda M, Hashizume H, et al Chronic compartment syndrome of the lower leg A new diagnostic method using near-infrared spec-troscopy and a new technique of endoscopic fasciotomy. Arthroscopy 1999 15 439-443. 29. Straehley D, Jones WW Acute compartment syndrome (anterior, lateral, and superficial posterior) following tear of the medial head of the...