David H. Gershuni

Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg

One hundred fifty-nine patients were referred to the authors for evaluation of chronic exertional leg pain from 1978 to 1987. The records of 131 patients were complete and available for retrospective review. Forty- five patients were diagnosed as having a chronic com partment syndrome (CCS) and seventy-five patients had the syndrome ruled out by intramuscular pressure recordings. The only significant difference found be tween the two groups on history and physical exami nation was a 45.9% incidence of muscle herniae in the patients with CCS, compared to a 12.9% incidence in those without the syndrome. One-third of the patients with the syndrome and over one-half of those without it reported persistent, moderate to severe pain at 6 month to 9 year followup. Modified, objective criteria were developed for the diagnosis of CCS. The criteria were based upon the intramuscular pressures recorded with the slit catheter before and after exercise in 210 muscle compartments without CCS. In the presence of appropriate clinical findings, we consider one or more of the following intramuscular pressure criteria to be diagnostic of chronic compartment syndrome of the leg: 1) a preex ercise pressure ≥ 15 mm Hg, 2) a 1 minute postexercise pressure of ≥30 mm Hg, or 3) a 5 minute postexercise pressure ≥20 mm Hg.

Management of chronic exertional anterior compartment syndrome of the lower extremity

Eighteen patients (28 compartments) with chronic exertional compartment syndrome and 14 normal asymptomatic volunteers (18 compartments) were studied. Evaluation included clinical assessment followed by quantitative determination of intracom-partmental pressures as monitored by wick or slit catheters before and after exercise. Intramuscular pressures measuring ≥10 mmHg at rest and/or ≥25 mmHg five minutes after exercise were defined as abnormally elevated. The patients with chronic compartment syndrome described reproducible exertional anterolateral leg pain, and 39% of these patients had a fascial hernia. Such a defect was present in less than five percent of the normal volunteers. Nonsurgical treatment was selected by five patients and all five reported persistent inability to participate in athletics because of their exertional pain. Of the remaining 13 patients, 12 were treated by decompressive fasciotomy and 11 of the 12 (92%) had pain relief and increased exercise tolerance. A single patient had had fascial closure instead of fasciotomy, and this procedure produced an acute compartment syndrome. Effective treatment of the chronic compartment syndrome consists of reduction of exertional activities or surgical decompression by fasciotomy.

Intramuscular deoxygenation during exercise in patients who have chronic anterior compartment syndrome of the leg

Currently, the definitive diagnosis of chronic compartment syndrome is based on invasive measurements of intracompartmental pressure. We measured the intramuscular pressure and the relative oxygenation in the anterior compartment of the leg in eighteen patients who were suspected of having chronic compartment syndrome as well as in ten control subjects before, during, and after exercise. Chronic compartment syndrome was considered to be present if the intramuscular pressure was at least fifteen millimeters of mercury (2.00 kilopascals) before exercise, at least thirty millimeters of mercury (4.00 kilopascals) one minute after exercise, or at least twenty millimeters of mercury (2.67 kilopascals) five minutes after exercise. Changes in relative oxygenation were measured with use of the non-invasive method of near-infrared spectroscopy. In all patients and subjects, there was rapid relative deoxygenation after the initiation of exercise, the level of oxygenation remained relatively stable during continued exercise, and there was reoxygenation to a level that exceeded the pre-exercise resting level after the cessation of exercise. During exercise, maximum relative deoxygenation in the patients who had chronic compartment syndrome (mean relative deoxygenation [and standard error], -290 ± 39 millivolts) was significantly greater than that in the patients who did not have chronic compartment syndrome (-190 ± 10 millivolts) and that in the control subjects (-179 ± 14 millivolts) (p < 0.05 for both comparisons). In addition, the interval between the cessation of exercise and the recovery of the pre-exercise resting level of oxygenation was significantly longer for the patients who had chronic compartment syndrome (184 ± 54 seconds) than for the patients who did not have chronic compartment syndrome (39 ± 19 seconds) and the control subjects (33 ± 10 seconds) (p < 0.05 for both comparisons). CLINICAL RELEVANCE: Patients who had chronic anterior compartment syndrome of the leg had greater relative deoxygenation during exercise as well as delayed reoxygenation after exercise; these findings support an ischemic etiology for chronic compartment syndrome. Near-infrared spectroscopy may be useful as a non-invasive diagnostic tool for the evaluation of patients suspected of having chronic anterior compartment syndrome of the leg.

Ankle and knee position as a factor modifying intracompartmental pressure in the human leg.

The objective of this study was to examine the effect of position of the knee and ankle on intracompartmental pressures in the leg. Slit catheters were introduced bilaterally into all four muscle compartments of the lower extremities of six healthy volunteers. Intracompartmental pressures were monitored with the catheters while the ankle joint was passively held in full dorsiflexion, full plantar flexion, or neutral with the knee flexed 90 or 10 degrees or fully extended. Statistical analysis revealed that intracompartmental pressure increased significantly in all four compartments when the ankle was passively dorsiflexed. Pressure in the superficial posterior and lateral compartments was dependent on knee position and in the deep posterior and anterior compartments it was independent of knee position. In addition, pressure in the deep posterior compartment decreased significantly when the ankle was placed in full plantar flexion, and that finding was independent of knee position. Anterior compartment pressure was not significantly elevated by full passive plantar flexion of the ankle.

Reduction of skeletal muscle necrosis using intermittent hyperbaric oxygen in a model compartment syndrome.

To study the effect of intermittent exposures to hyperbaric oxygen on experimentally induced compartment syndrome in the hind limbs of twelve dogs, we produced a compartment syndrome by infusion of autologous plasma during general anesthesia. Intracompartmental pressures, monitored with wick and slit catheters, were maintained at thirty, sixty, or 100 millimeters of mercury for eight hours in three groups of dogs. Immediately after the infusion was stopped, each dog was placed in a monoplace hyperbaric chamber that was pressurized to two atmospheres absolute for one hour. During the next ten hours the same dogs received two additional one-hour exposures to hyperbaric oxygen, with a four-hour break between each exposure. Forty-eight hours after the infusion, skeletal muscle necrosis was quantified by intravenous injection of technetium-99m stannous pyrophosphate. Three hours later each dog was killed and samples from the pressurized and control anterior-compartment muscles were processed for histological examination and counted for uptake of the technetium. The results were compared with the findings in twenty-five dogs that were not exposed to hyperbaric oxygen after infusion. Muscle necrosis, quantified by uptake of technetium-99m, was signiticantly reduced (p < 0.01) after exposures to hyperbaric oxygen as compared with the necrosis that was produced in muscles of dogs that were not exposed to hyperbaric oxygen. Treatments with hyperbaric oxygen effectively reduced edema in the experimental compartment. At 100 millimeters of mercury the ratio of the weight of the muscles from the experimental anterolateral compartment to the weight of the muscles .. Supported by the Veterans Administration. by United States Publie Health Service National Institutes of Health Grants AM-25501 . AM26344. and RCI)A AM-0()602 to Dr. Hargcns. and by the Baromedical FoundatIon, MemorIal HospItal Medlcal Center. Long Beach. Califor-

Wide tourniquet cuffs more effective at lower inflation pressures.

Longitudinal and radial tissue-fluid pressure distributions were determined beneath and adjacent to wide (12 and 18 cm) pneumatic tourniquet cuffs placed on intact human cadaveric arms and legs, respectively. Tissue fluid pressures exhibited relatively broad maxima at midcuff, and in most cases showed no differences at the various depths studied. Limb circumference was not a determining factor in the transmission of pressure to deeper tissue. We also investigated the effect of four cuff sizes (4.5, 8, 12, and 18 cm) on eliminating blood flow to the lower legs of normal subjects. The cuff pressure required to eliminate blood flow decreased as cuff width increased; thigh circumference was a determining factor in the pressure required to eliminate blood flow while using the smaller cuffs, but not while using the 18-cm cuff. Thus, wide cuffs transmit a greater percentage of the applied tourniquet pressure to deeper tissues than conventional cuffs; accordingly, lower cuff pressures are required, which may minimize soft-tissue damage during extremity surgery.

Hyperbaric oxygen reduces edema and necrosis of skeletal muscle in compartment syndromes associated with hemorrhagic hypotension.

This study examined the effect of exposures to hyperbaric oxygen on the development of the edema and necrosis of muscle that are associated with compartment syndromes that are complicated by hemorrhagic hypotension. A compartment syndrome (twenty millimeters of mercury for six hours) was induced by infusion of autologous plasma in the anterolateral compartment of the left hind limb of seven anesthetized dogs while the mean arterial blood pressure was maintained at sixty-five millimeters of mercury after 30 per cent loss of blood volume. These dogs were treated with hyperbaric oxygen (two atmospheres of pure oxygen) and were compared with six dogs that had an identical compartment syndrome and hypotensive condition but were not exposed to hyperbaric oxygen. Forty-eight hours later, edema was quantified by measuring the weights of the muscles (the pressurized muscle compared with the contralateral muscle), and necrosis of muscle was evaluated by measuring the uptake of technetium-99m stannous pyrophosphate. The ratio for edema was significantly (p = 0.01) greater in dogs that had not been exposed to hyperbaric oxygen (1.15 +/- 0.01) than in the dogs that had been treated with hyperbaric oxygen (1.01 +/- 0.03), and the ratio for necrosis of muscle was also significantly (p = 0.04) greater in dogs that had not had hyperbaric oxygen (1.96 +/- 0.41) than in those that had been treated with hyperbaric oxygen (1.05 +/- 0.11). Comparisons were also made with the muscles of four normal control dogs and separately with the muscles of six normotensive dogs that had an identical compartment syndrome and normal blood pressure and were not treated with hyperbaric oxygen.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of ankle position and a plaster cast on intramuscular pressure in the human leg.

Intramuscular pressure was measured with transducer-tipped catheters that had been inserted into the anterior and deep posterior compartments of the leg in seven healthy adults. Intramuscular pressure increased three to sevenfold (depending on the position of the ankle) in both compartments after the application of a plaster cast from the proximal part of the thigh to the malleoli. While the cast was in place, the baseline intramuscular pressure was elevated by the inflation of a tourniquet, which was located on the proximal part of the thigh, to a pressure of sixty millimeters of mercury (8.00 kilopascals). The intramuscular pressure in both the anterior and the deep posterior compartments was found to be lowest when the ankle joint was between the neutral and the resting positions (between 0 and 37 degrees of flexion). After the cast was bivalved and the opening on each side was spread approximately one-half centimeter, there was a significant decrease in intramuscular pressure of 47 per cent in the anterior compartment and of 33 per cent in the deep posterior compartment (p < 0.05 for both).

Effects of tourniquet compression on neuromuscular function.

Neuromuscular function in New Zealand White rabbits was evaluated after thigh tourniquet compression in the directly compressed quadriceps muscles and the distal tibialis anterior by measuring isometric contractile function after supramaximal stimulation of the motor nerve. Tourniquet compression resulted in markedly decreased force production beneath and distal to the tourniquet. Two days after compression, maximal quadriceps force production was decreased to 46% of control values with 125 mm Hg compression and 21% of control values after 350 mm Hg compression. Maximum tibialis anterior force production declined to 70% of control values after 125 mm Hg thigh compression and 24% of control values after 350 mm Hg thigh compression. Functional deficits were greater in the directly compressed quadriceps muscles, but the quadriceps and tibialis anterior had significantly increased impairment when the tourniquet inflation pressure was increased from 125 mm Hg to 350 mm Hg. Three weeks after compression, quadriceps function had returned to 94% of control value after 125 mm Hg compression and 83% after 350 mm Hg. Tibialis anterior function returned to 88% of control values after 125 mm Hg thigh compression and 83% after 350 mm Hg. Clinically, the use of lower inflation pressures may minimize the complications of tourniquet use and enhance postoperative recovery.

The use of lower tourniquet inflation pressures in extremity surgery facilitated by curved and wide tourniquets and an integrated cuff inflation system

Use of the lowest possible cuff inflation pressure should minimize the pathogenic effects of compression beneath the pneumatic tourniquet. Curved tourniquets (designed to fit conically shaped limbs) and wider tourniquets were associated with significantly lower arterial occlusion pressure (AOP) than standard, straight tourniquets on the arms and legs of 26 normal volunteers. These tourniquets were used with an integrated tourniquet inflation system in 29 upper-extremity and 31 lower-extremity surgeries. Mean tourniquet inflation pressures of 183.7 mm Hg and 208 mm Hg were used during various surgical procedures of the arm and leg, respectively. Incomplete hemostasis was associated with elevated systolic blood pressure in several cases, but acceptable surgical hemostasis was achieved by incremental increase of the cuff inflation pressure. Curved cuffs, wide cuffs, and an integrated cuff inflation system should facilitate the use of lower tourniquet inflation pressures in extremity surgery.