Jocelyn R. Wittstein, L. Scott Levin, and Claude T. Moorman III
DEFINITION
Compartment syndrome can be either acute or chronic.
Acute compartment syndrome usually is due to trauma to, or reperfusion of, the extremity. Chronic exertional compartment syndrome (CECS) often is associated with the repetitive loading or microtrauma of endurance activities.
Both acute and chronic compartment syndromes are due to increased interstitial pressure within a compartment, resulting in decreased perfusion and ischemia of soft tissues.
In contrast to the reversible nature of CECS, acute compartment syndromes progress rapidly and require urgent fasciotomy to avoid irreversible soft tissue necrosis in the affected compartment.
Wilson first described the concept of CECS in 1912, but Mavor12 was the first to successfully treat a patient with anterior compartment syndrome of the leg using a fasciotomy.
Clinical manifestations of exercise-induced pain relieved by rest, swelling, numbness, and weakness of the extremity have long been attributed to elevated intracompartmental pressures.5,17
The true incidence of CECS is unknown, but one study reported a prevalence of 14% among individuals with lower leg pain.16
CECS often is bilateral and is equally prevalent among males and females.
Case reports of CECS of the forearm, thigh, and gluteal regions exist, but are rare.7,9,10
The leg is the most common site, with the anterior and lateral compartments most frequently affected. This chapter focuses on CECS of the leg.
ANATOMY
The leg contains four compartments: anterior, lateral, superficial posterior, and deep posterior (FIG 1).
The anterior compartment contains the anterior tibial artery, the deep peroneal nerve, and four muscles (tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius). Its borders are the tibia, fibula, interosseus membrane, anterior intermuscular septum, and deep fascia of the leg.
FIG 1 • Cross-sectional anatomy of the leg.
The lateral compartment contains the superficial peroneal nerve and two muscles (peroneus longus and peroneus brevis).
The common peroneal nerve braches into the superficial and deep peroneal nerves within the substance of the peroneus longus after passing along the neck of the fibula.
The superficial peroneal nerve continues within the lateral compartment, while the deep peroneal nerve wraps around the fibula deep to the extensor digitorum longus until reaching the anterior surface of the interosseus membrane.
The lateral compartment does not contain a large artery; the peroneal muscles receive their blood supply via several branches of the peroneal artery.
The lateral compartment is bordered by the anterior intermuscular septum, the fibula, the posterior intermuscular septum, and the deep fascia.
The superficial posterior compartment contains the sural nerve and three muscles (gastrocnemius, soleus, and plantaris) and is surrounded by the deep fascia of the leg.
The deep posterior compartment contains the posterior tibial and peroneal arteries, tibial nerve, and four muscles (flexor digitorum longus, flexor hallucis longus, popliteus, and tibialis posterior).
It is bordered anteriorly by the tibia, fibula, and interosseus membrane, and posteriorly by the deep transverse fascia.
A fifth compartment that encloses the tibialis posterior muscle has been described,3 but its existence is controversial. It has been suggested that the presence of an extensive fibular origin of the flexor digitorum longus muscle may create a subcompartment within the deep posterior compartment that may develop elevated pressures.8
PATHOGENESIS
The etiology of CECS is not entirely understood. It is thought to be due to an abnormal increase in intramuscular pressure during exercise resulting in impaired local perfusion, tissue ischemia, and pain.
Contributing factors may include exertion-induced swelling of the muscle fibers, increased perfusion volume, and increased interstitial fluid volume within a constrictive compartment.
The elevated intramuscular pressure decreases arteriolar blood flow and diminishes venous return.
This, in turn, results in tissue ischemia and accumulation of metabolites.
Elevated lactate levels and water content have been documented in muscle biopsies from compartments with elevated pressures following exercise.16
Muscle hypertrophy and increased perfusion volume with exertion do not explain the elevated resting pressure seen in patients with CECS, however. The mechanical damage theory hypothesizes that heavy exertion results in myofibril damage, release of protein-bound ions, increased osmotic pressure in the interstitial space, and, therefore, decreased arteriolar flow in the compartment.
Additionally, in some cases focal fascial defects may be a contributing factor.
Anterolateral fascial hernias are present in 39% to 46% of patients with CECS, as compared to less than 5% of asymptomatic individuals.6,25
FIG 2 • The superficial peroneal nerve can become entrapped at a fascial defect.
These defects typically are located near the anterior intermuscular septum between the anterior and lateral compartments and can entrap the superficial peroneal nerve exiting the junction of the middle and distal thirds of the leg (FIG 2).
None of the existing theories explain all the available data on the etiology of CECS. Most likely, the pathogenesis of the elevated intracompartmental pressures seen in CECS is multifactorial.
NATURAL HISTORY
CECS of the leg is a common injury in people involved in running and endurance sport activities, such as young athletes and military personnel.
Pain, as well as occasional numbness and weakness, develops at a predictable interval after initiation of a repetitive, endurance type activity and resolves with rest.
The symptoms are longstanding and recurrent, because patients tend to self-limit but then subsequently attempt to resume activities.
PATIENT HISTORY AND PHYSICAL FINDINGS
The following symptoms may be present upon exertion and resolve with rest:
A sensation of cramping, burning, aching, or tightness in the region of the affected compartment(s)
Numbness or weakness in the extremit.
A transient footdrop may develop if the deep peroneal nerve is affected.
A temporary loss of eversion strength may occur if the superficial peroneal nerve is affected.
Physical examination of the resting lower extremity often is unremarkable.
Examination following exercise may reveal.
Increased tightness of the involved compartments
If a fascial defect is present, a focal area of tenderness and swelling may develop as the underlying muscle bulges through the defect.
A positive Tinel's sign over the defect if the superficial peroneal nerve is compressed
When the history and physical examination findings are consistent with CECS, the diagnosis should be confirmed with preand postexercise compartment pressure measurements.
Most clinicians follow the diagnostic criteria of Pedowitz et al,15 in which a resting pressure greater than or equal to 15 mm Hg or a 1-minute postexercise measurement greater than or equal to 30 mm Hg or a 5-minute postexercise measurement greater than or equal to 20 mm Hg is considered abnormal and diagnostic of CECS.
The exercise performed at the time of testing must be intense enough to reproduce the patient's symptoms; otherwise, the postexercise pressure measurements may be falsely low.
Several methods for measuring compartment pressures have been described in the literature.
These include the slit catheter, wick catheter, needle manometery, digital pressure monitor, microcapillary infusion, and solid-state transducer intracompartmental catheter methods.1,2,13,14,19,25
The Stryker inracompartmental pressure monitor (Kalamazoo, MI) is a handheld digital monitor that can be used to check multiple compartments. It can be used with a side port needle or with an indwelling slit catheter to obtain serial measurements in a single compartment.
A new handheld digital device recently developed by Synthes (Paoli, PA) also allows placement of indwelling catheters and may be useful for obtaining serial measurements.
Near-infrared spectroscopy has been used to determine tissue oxygen saturation.26 This may be a noninvasive, painless alternative to intracompartmental pressures in the diagnosis of CECS, but is not currently standardized or readily available.
The vibration test consists of placing a vibrating tuning fork over bone at the area of suspected stress; an elicitation of pain is consistent with a stress fracture.
Pain when performing resisted ankle dorsiflexion and inversion is consistent with tibialis posterior tendinitis or posteromedial periostitis.
IMAGING AND OTHER DIAGNOSTIC STUDIES
When pressure measurements are not consistent with CECS, further diagnostic studies may be necessary to explore the differential diagnosis.
Plain radiographs may demonstrate a periosteal reaction in patients with tibial stress fractures or posteromedial tibial periostitis.
Bone scan will show increased uptake, and MRI may show edema or a black line at the site of a stress fracture.
Tingling, numbness, or a positive Tinel's sign at a specific location may warrant an EMG and nerve conduction study to evaluate for peripheral nerve entrapment.
DIFFERENTIAL DIAGNOSIS
Tibial stress fractures
Posteromedial tibial periostitis
Tenosynovitis of posterior tibialis or ankle dorsiflexors
Peripheral nerve entrapment
Radiculopathy secondary to lumbar pathology
Complex regional pain syndrome
Peripheral vascular disease
Popliteal artery entrapment syndrome
Deep venous thrombosis
NONOPERATIVE MANAGEMENT
Nonoperative management usually requires activity limitation.
Symptoms usually return with resumption of prior activity level. Surgery, therefore is indicated in patients who cannot tolerate activity restriction.
SURGICAL MANAGEMENT
Surgical treatment involves fasciotomy of the affected compartments, sometimes with partial fasciectomy.
Patients who are unable to maintain their desired activity level owing to symptoms of CECS are appropriate operative candidates.
Preoperative Planning
It is critical to identify which compartments are affected.
All symptomatic compartments should be addressed at the time of surgery. It is common for a failed index procedure to be due to a failure to release an affected compartment.
The appropriate approach should be selected based on the compartments that need to be released.
Positioning
The patient is placed in the supine position for each technique.
Approach
A single or dual-incision technique can be used to release the lateral and anterior compartments.
The perifibular approach can be used to access all four compartments.
A second posteromedial approach offers easier access to the superficial and deep posterior compartments.
Endoscopically assisted fasciotomies allow access to the entire length of the compartment, allow visualization of fascial hernias, and may minimize surgical complications such as postsurgical fibrosis and injury to the superficial peroneal nerve.
The safety and effectiveness of endoscopically assisted compartment release has been demonstrated in cadavers.11
A technique using balloon dissectors and carbon dioxide insufflation is described in the Technique section.27
TECHNIQUES
SINGLE-INCISION LATERAL APPROACH FOR ANTERIOR AND LATERAL COMPARTMENT FASCIOTOMY
The patient is placed in the supine position on the operating table.
A 5-cm vertical incision is made halfway between the fibular shaft and the tibial crest at the midportion of the leg. The incision should lie over the anterolateral intermuscular septum (TECH FIG 1A).
If a focal fascial defect is present, the incision should be adjusted so that the defect can be incorporated.
A small transverse incision is made just through the fascia, and the septum and the superficial peroneal nerve, which lie near the septum in the lateral compartment and exit the fascia near the distal aspect of the incision, are identified (TECH FIG 1B).
Longitudinal releases of the anterior and lateral compartments are performed using long Metzenbaum scissors in a proximal and distal direction from the transverse incision in the fascia that crosses over the anterolateral intermuscular septum (TECH FIG 1C).
A partial fasciectomy may be performed, particularly in cases of recurrence following a prior fasciotomy.
The fascia is left open.
The subcutaneous tissue is approximated using 2-0 absorbable suture material.
The skin is closed with a running subcuticular 4-0 nonabsorbable suture material and Steri-strips.
TECH FIG 1 • Single-incision lateral approach. A. A 5-cm vertical incision is made halfway between the fibular shaft and the tibial crest over the anterolateral intermuscular septum. B. A small transverse incision is made just through the fascia, and the superficial peroneal nerve is identified. C. Longitudinal releases of the anterior and lateral compartments are performed using long Metzenbaum scissors.
DUAL INCISION LATERAL APPROACH FOR ANTERIOR AND LATERAL COMPARTMENT FASCIOTOMY
The patient is placed in a supine position.
The leg is divided into thirds, and two 3-cm incisions are placed at the junction of the thirds over the anterolateral intermuscular septum (TECH FIG 2A,B).
The superficial peroneal nerve is identified as it exits the fascia near the distal incision (TECH FIG 2C).
Fasciotomies of the anterior and lateral compartments are performed on each side of the intermuscular septum (TECH FIG 2D).
The incisions in the fascia are connected using Metzenbaum scissors to divide the fascia from the proximal incision toward the knee (TECH FIG 2E), then from the proximal incision toward the distal incision, and finally from the distal incision toward the ankle (TECH FIG 2F).
TECH FIG 2 • Dual-incision approach. A. The leg is visually split into thirds, and two 3-cm incisions are placed at the junction of the thirds over the anterolateral intermuscular septum. B. The superficial peroneal nerve is located 10 to 12 cm proximal to the tip of the lateral malleolus. The inferior incision is centered over this area. C. Dissection of the superficial peroneal nerve. D. A fascial defect often is present in this area, and compartment releases should be centered over these areas if possible. E. The incisions in the fascia are connected using Metzenbaum scissors to divide the fascia. F. Long scissors are used and are opened only slightly at the tips. (B–D,F:Courtesy of Mark D. Miller, MD.)
Distally, the fasciotomy should extend to 4 to 6 cm proximal to the ankle.
At the distal aspect of the anterior compartment, the release should be directed more toward the midline to minimize risk of injuring cutaneous sensory nerves at the lateral aspect of the compartment.
The distal aspect of the lateral compartment fasciotomy should be directed more laterally.
The subcutaneous tissue is closed with 2-0 absorbable suture material.
The skin is closed with running subcuticular 4-0 sutures and Steri-strips.
PERIFIBULAR APPROACH FOR FOUR-COMPARTMENT FASCIOTOMY
The patient is placed in the supine position.
A 10-cm incision is made directly over the midportion of the fibula (TECH FIG 3A).
The skin is retracted anteriorly and the fascia of the anterior and lateral compartments is released longitudinally in a proximal and distal direction (TECH FIG 3B).
The skin is retracted posteriorly.
The fascia overlying the lateral head of the gastrocnemius is released.
The fascia over the superficial posterior compartment is incised for a distance of about 15 cm.
TECH FIG 3 • Perifibular approach. A. A 10-cm incision is made directly over the midportion of the fibula. B. The skin is retracted anteriorly, and the fascia of the anterior and lateral compartments is released longitudinally. C. The anterior and lateral compartments are retracted anteriorly and the superficial posterior compartment posteriorly, and the soleal bridge is released from the fibula.
The anterior and lateral compartments are retracted anteriorly and the superficial posterior compartment posteriorly. The soleal bridge must be released from the fibula (TECH FIG 3C).
The fascia over the flexor hallucis longus is identified and incised.
The gastrocsoleus is retracted posteriorly and the flexor hallucis longus laterally to expose the posterior tibial artery, tibial nerve, and peroneal artery overlying the tibialis posterior.
The fascia is incised around the tibialis posterior and the interval between the muscle and the origins of the flexor hallucis longus is widenend if it is constrictive.
The subcutaneous tissue is approximated with 2-0 absorbable suture.
The skin is closed with running subcuticular nonabsorbable 4-0 suture.
POSTEROMEDIAL INCISION FOR FASCIOTOMY OF THE POSTERIOR COMPARTMENTS
A vertical incision 8 to 10 cm in length is made over the midportion of the leg approximately 1 cm posterior to the posteromedial edge of the tibia (TECH FIG 4A).
The saphenous vein and nerve are identified in the subcutaneous tissue and retracted anteriorly.
The fascia over the superficial posterior compartment is incised for a distance of about 15 cm (TECH FIG 4B,C).
To fully access the deep posterior compartment, the origin of the soleus from the proximal tibia and fibula must be detached (TECH FIG 4D).
The deep fascia can then be sharply divided with Metzenbaum scissors (TECH FIG 4E–G).
The fasciotomy should extend distally to 8 to 10 cm above the ankle.
The opening between the origins of the flexor hallucis longus and the tibialis posterior is enlarged if constrictive.
The subcutaneous tissue is closed with 2-0 absorbable suture.
The skin is closed with running subcuticular nonabsorbable 4-0 suture.
TECH FIG 4 • Medial approach. A. An 8to 10-cm vertical incision is made over the midportion of the leg approximately 1 cm posterior to the posteromedial edge of the tibia. B,C. Superficial compartments are released. D.The origin of the soleus from the proximal tibia and fibula is detached. E. The deep fascia is sharply divided with Metzenbaum scissors. F,G. Deep posterior compartments are released. (B,C,F,G: Courtesy of Mark D. Miller, MD.)
ENDOSCOPICALLY ASSISTED COMPARTMENT RELEASE
The patient is placed in a supine position.
Balloon dissectors can be used to create an optical cavity at the fascial cleft, which is the potential space between the superficial fascia (the deepest layer of the skin and subcutaneous tissue) and the deep fascia (the fascia overlying a muscle compartment; TECH FIG 5).
To insert the balloon dissector, a 2-cm transverse incision is made either at the anterolateral aspect of the knee between the fibular head and Gerdy's tubercle or at the posteromedial aspect of the knee at the level of the tibial crest.
Dissection is carried down through the subcutaneous fat and superficial fascia until the deep fascia overlying the muscle is visualized.
The balloon dissector with a sheath around it is inserted between the superficial and deep fascial layers under direct observation and manual palpation to the level of the ankle.
The sheath is removed and the balloon is inflated to create a cavity within the fascial cleft.
The balloon is then deflated and removed.
A one-way cone-shaped cannula is inserted in the skin at the site of balloon insertion.
The optical cavity between the superficial and deep fascial layers can be maintained subsequently with 15 mm Hg of carbon dioxide insufflation to allow adequate visualization of the fascia to be released and to allow adequate space to perform soft tissue dissection with the endoscopic equipment.
Alternatively, the cavity is not insufflated, but is maintained with towel clips externally.
Next, the fascia is released with endoscopic scissors down to the level of the ankle under direct vision.
If necessary, a distal instrument portal with a pneumatic lock can be placed, but the fasciotomies usually are carried out proximal to distal through the initial portal.
After the release, the cannula is removed and the cavity is deflated.
The wound is closed in a two-layer fashion with 2-0 Vicryl for the deep layer and a running subcuticular stitch for the skin over a medium Hemovac drain.
TECH FIG 5 • Sequential demonstration of balloon placement in the lower extremity. A. Portal incisions for balloon insertion. B. Balloon parallel to the leg in disassembled position. C. Entry of balloon. D.Sheath removed. E. Balloon inflated. F. Balloon deflated. G. Balloon removed. H. Balloon inflated to confirm complete removal of dissector balloon. I. Portal advancement. J. Portal placed into skin by turning clockwise. K. Guide rod withdrawn. L. Endoscope inserted proximally. (Reprinted with permission from Zobrist R, Aponte R, Levin LS. Endoscopic access to the extremities: the principle of fascial clefts. J Orthop Trauma 2002;16:264–271.)
POSTOPERATIVE CARE
Active range of motion at the ankle and knee should begin immediately.
Crutches can be used as needed in the initial postoperative period, but patients are encouraged to bear weight as tolerated and perform light activities.
Elevation of the legs while at rest may help to decrease pain and swelling.
Full activity usually can be resumed 4 to 6 weeks after surgery.
OUTCOMES
Various techniques of compartment release have reports of success rates ranging from 81% to 100%.4,6,18,20,22,24
These techniques include open fasciotomies, oneor twoincision minimally invasive subcutaneous fasciotomies, and fasciotomies with partial fasciectomies.
Adequate long-term follow-up is lacking in the literature.
Slimmon et al reported on long-term follow-up of patients treated with fasciotomy with partial fasciectomy and noted a good or excellent outcome in 60% at a mean follow-up of 51 months. Thirteen of 62 had reduced activity levels due to recurrence of symptoms or development of a different lower extremity compartment syndrome.23
Fasciotomy appears to be less effective in alleviating pain in the deep posterior compartment than in other compartments.
Some authors have postulated that failure of the fasciotomy may be due to an incomplete fasciotomy or not identifying and releasing the fascia around the tibialis posterior.3,18,20
COMPLICATIONS
Recurrence rates of 3% to 17% have been reported after fasciotomy.4,18,20,22
Recurrence may be due to a number of factors, including inadequate fascial releases, failure to decompress a compartment that was believed to be asymptomatic, nerve compression by an unrecognized fascial hernia, and the development of prolific scar tissue.21
Other reported complications of fasciotomies with some degree of subcutaneous or blind dissection include arterial injury, hematoma or seroma formation, superficial wound infections, peripheral cutaneous nerve injuries, and deep venous thromboses.4,6,23
The superficial peroneal nerve is particularly vulnerable as it exits the fascia over the lateral aspect of the leg at the junction of the middle and distal thirds.
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