LEGALLY SHEET

Refference article (Refrat) by title Compartment Syndrome of Lower Leg is arranged to complete the requirement in Orthopaedic and Traumatology Department Sebelas Maret University, Moewardi Hospital /Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta by: Bobbi Juni Saputra G99101324 Has been approved by Tutor of Orthopaedic and Traumatology Department in Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta.

Surakarta, Septermber 2013 Tutor

dr. Tangkas Sibarani, SpOT,FICS

CHAPTER I INTRODUCTION

Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells. Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged. Compartment Syndrome can be either acute or chronic. Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage. Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion. Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged. In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome. Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.

CHAPTER II BIBLIOGRAPHY

A. Anatomy and Physiology

Compartments are groupings of muscles, nerves, and blood vessels in our arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.

The lower leg has four compartments. These four compartments are bordered by the tibia, fibula, interosseous membrane and the surrounding fasciae. The anterior compartment contains the profound peroneal nerve, tibial anterior

muscle, extensor hallucis longus and extensor digitorum muscle. In the lateral compartment are the nervus peroneus communis and superficial peroneal nerve, the peroneus longus and brevis muscle. In the deep posterior compartment are the arteria, vena and nervus tibialis, the posterior tibial muscle, musculus flexor hallucis longus and flexor digitorum longus. The superficial posterior compartment consists of the sural nerve, the gastrocnemius muscle and the soleus muscle.

B. Compartment Syndrome 1. Definition a. Acute Compartment Syndrome Acute compartment syndrome (ACS) is a surgical emergency. Diagnosis depends on a high clinical suspicion and an understanding of risk factors, pathophysiology and subtle physical exam findings. The typical high risk scenario for ACS is mosty for a male patient younger than 35 years of age, involved in a high energy sport or roadway collision, resulting in a tibial shaft fracture and it is required emergent fasciotomy. Diagnosis of ACS in this patient is primarily a clinical one but can be confirmed with invasive intracompartmental pressure monitoring or non-invasive near infrared spectroscopy (NIRS). b. Chronic Compartment Syndrome Chronic (Exertional) compartment syndrome of the leg is a condition that can cause chronic debilitating pain in active persons during a variety of aerobic activities. Chronic (Exertional) compartment syndrome is an activity-related condition that typically affects young active persons. Clinical signs include pain in the lower leg musculature that worsens with activity. The pathophysiology is somewhat unclear, but a temporary relative ischemia in the lower leg appears to be involved. This induces swelling and results in increased intracompartmental pressure.

2. Epidemiology Acute compartment syndrome commonly develops in traumatized patients with distracting or neurologically inhibiting injuries. The physician must have a high degree of suspicion when treating these patients. Time to diagnosis is the most important prognostic factor for these patients. Insufficient understanding of the natural history and limited evaluation of signs and symptoms primarily account for delays in diagnosis. Several risk factors can aid in making the diagnosis. Age is a major risk factor for developing ACS. Patients younger than 35 years of age are more likely than older patients to develop ACS following the same type of injury. ACS is most commonly seen in tibial shaft fractures, accounting for one third of all cases. Isolated soft tissue injuries account for a quarter of ACS cases and forearm fractures account for a fifth of them. ACS is ten times more common in males. There is no difference in incidence of ACS in open compared to closed fractures. There are a multitude of less common causes of ACS including snake bites, nephrotic syndrome, IV infiltrations, and other volume expanding disorders.

3. Pathophysiology ACS occurs as a result of two factors occurring in isolation or simultaneously: an increase in the contents of an enclosed space (e.g. bleeding) and/or a decrease in the volume of a space (e.g. tight cast). Compartment syndrome occurs when the interstitial pressure within the compartment exceeds the perfusion pressure at the level of the capillary beds. Elevated intracompartmental pressure (ICP) leads to increased pressure at the venous end of the capillary beds causing increased hydrostatic pressure and further increase in ICP, eventually leading to arteriolar compression. Loss of the perfusion pressure gradient results in the onset of ischemia and ultimately leads to cellular anoxia and death.

At the cellular level, diminishing ATP levels correlate closely with worsening muscle necrosis. In a canine study, after six hours of ischemia, only 20 % of pre-ischemic ATP remained which led to complete muscle necrosis [7]. Histologic analysis revealed central muscle necrosis with a surrounding zone of partial ischemia and peripheral tissue edema, often within areas of incomplete injury 4. Clinical Diagnosis 5. Compartment syndrome is, for the most part, a clinical diagnosis. It is a diagnosis that is made over time as the evolution of signs and symptoms are assessed, rather than a diagnosis made in isolation at a single time point. Serial examinations should always be performed, preferably by the same, experienced examiner. 6. The classic Ps described in compartment syndrome are pain, paresthesia, paralysis/paresis, pulselessness, and pallor. Although all have a role in the diagnosis of compartment syndrome, the constellation of signs and symptoms and overall clinical picture are more important than the presence or absence of any particular finding.

7. 8. Picture 1. Clinical example of Acute Compartment Syndrome (Right Leg). Notice the markedly increased swelling compared to the contralateral side, as well as skin changes. This patient was the victim of a gunshot injury to the leg

9. Rontgen Finding Patient A, a healthy 28-year-old female, was seen at the Emergency Department of a regional hospital after an accident with her scooter; she hit a post with her lower leg. She was treated according to the principles of the Advanced Trauma Life Support (ATLS). The patient had only sustained a comminuted fracture of the left tibial plateau (Pic 2). A CT-scan of the left knee was performed and the joint was temporarily immobilised with an upper plaster splint. The patient was hospitalised. One and a half days after the accident, motor function was absent in the lower left leg and absence of sensation in the foot was noted. ACS was diagnosed and a four compartment fasciotomy was performed to decompress the lower leg compartments. The patient was transferred to a central hospital for further treatment of the tibial

fracture. Upon inspection under anaesthesia (for particular evaluation of muscle vitality) four days after trauma, the muscle tissue of the anterior, peroneal and deep flexor compartments was not vital. Of the superficial flexor compartment, only the medial muscle belly of the gastrocnemius muscle was still vital. After consultation with the patient, it was decided that in view of the prognosis associated with absent sensation and motor function in the lower leg and the fact that she became seriously ill because of tissue necrosis, the appropriate course of action was performance of an upper amputation. Seven days after the accident, a transfemoral amputation was carried out. Next the patient underwent outpatient rehabilitation with an upper leg prosthesis.

Picture 2. Comminuted left tibial plateau fracture (Schatzker V) of patient A.

Patient B, a healthy 30-year-old man, sustained a right proximal crural fracture as a result of a direct trauma during a soccer match (Pic 3). For this, he was admitted to a regional hospital and operated on the same day. The proximal fracture of the right lower leg was stabilised with an intramedullary nail (Pic 4). The next day, the patient developed an ACS of the right lower leg, for which a four compartment fasciotomy was performed with a medial and lateral incision. The postoperative course was complicated by increasing pain symptoms of the right lower leg, as well as high fever. Because a wound infection was suspected, a course of intravenous antibiotics was begun. The patient was followed up with MRI-scans to rule out a deep infection or osteomeyelitis. On these scans, a collection of fluid was seen; therefore, an exploration and drainage of the wound was carried out. The wound was treated with a vacuum system. Due to a lack of healing, the patient was transferred after one month to a central hospital for a second opinion. At the first outpatient visit, the patient still experienced much pain in the proximal lower leg. Sensation was almost completely absent in the foot and the lateral lower leg. No extension or flexion of the foot or toes was possible. Upon wound inspection, free exposed bone was found. Neurological examination showed complete loss of the peroneal and tibial nerves. It was decided to admit the patient for wound exploration under general anaesthesia in the operation room. Necrosis of the anterior, peroneal and deep flexor compartments was found. Only the superficial flexor compartment (proximal area) showed some vital muscle tissue. After consultation with the patient and his partner, it was decided to perform a transfemoral amputation. The postoperative course was marked by serious coping problems. This patient also started upon an outpatient rehabilitation course with upper leg prosthesis.

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Picture 3

Picture 4

Picture 3. Proximal right lower leg fracture of patient B. Picture 4. Situation of patient B after intramedullary nail fixation and fasciotomy of the right lower leg.

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10. Treatment Successful treatment of ACS requires surgical decompression as early as possible by way of a four-compartment fasciotomy. Hence, the causes of external pressure also have to be removed, including a compressing bandage or plaster. An expectant position and (diagnostic) delays lead to serious complications. A direct relation exists between the time passed before the performance of a fasciotomy and the final functional result. An untreated compartment syndrome leads to loss of muscle tissue, hyperkalaemia, metabolic acidosis, renal insufficiency, amputation of extremities and sometimes death. The four compartments can be approached through one lateral incision or through a lateral and medial incision. It is important to make the skin incisions long enough (at least 16 cm) so that all compartments are sufficiently decompressed .The skin incision is left open so that later, after the swelling subsides, the wound can be closed.

11. Prognosis A late diagnosis of ACS of the lower leg and the failure to perform an emergency fasciotomy can lead to the loss of an extremity. It is of the greatest possible importance to be alert for the symptoms that can point to the beginning of a compartment syndrome. This compartment syndrome can exist in children as well, as demonstrated by the cases formerly described. As early as possible, one has to think of the ACS, so that treatment may be begun as early as possible. The elapsed time between the onset of an ACS and treatment determines the ultimate result. Therefore, this period has to be as short as possible. The case histories, which are described in this clinical lecture, show that ACS is sometimes difficult to diagnose and cases are for this reason rather often missed with serious consequences for the patient.

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CHAPTER III CONCLUSION

Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells. Compartment syndrome develops when swelling or bleeding occurs within a compartment. Compartmentsyndrome is divided into 2 types, Acute Compartment Syndrome and Chronic Compartment Syndrome. A late diagnosis of ACS of the lower leg and the failure to perform an emergency fasciotomy can lead to the loss of an extremity. It is of the greatest possible importance to be alert for the symptoms that can point to the beginning of a compartment syndrome. The typical high risk scenario for ACS is mosty found in male patient younger than 35 years of age and Chronic chronic compartment syndrome pathophysiology is somewhat unclear, but a temporary relative ischemia in the lower leg appears to be involved. This induces swelling and results in increased intracompartmental pressure.

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REFFERENCE

Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003;85(5):62532. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851121/ (September 2013) Gourgiotis S, Villias C, Germanos S, Foukas A, Ridolfini MP. Acute limb compartment syndrome: A review. J Surg Educ. 2007;64(3):17886. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851121/ (September 2013) Reneman R.S. The anterior and the lateral compartmental syndrome of the leg due to intensive use of muscles. Clin Orthop Relat Res. 1975;113:6980. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716236/ (September 2013) Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint Surg Br. 1984;66(1):937.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851121/ (September 2013) Ryan M.Taylor, Matthew P Sullivan, Samir Mehta. Acute compartment syndrome : obtaining diagnosis, providing treatment, and minimizaing medicolegal risk.2012;5(3): 206-213.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Acute+compartment+syndro me+%3A+obtaining+diagnosis%2C+providing+treatment%2C+and+mini mizaing+medicolegal (September 2013).

AAOS.

Compartment

Syndrome.

http://orthoinfo.aaos.org/topic.cfm?topic=a00204 (September 2013).

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