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    Anterior Compartment Syndrome (Anterior Compartment Syndromes)

    Anterior compartment syndrome implies development of increased pressure within the anterior compartments of the body. The lower leg is the most common site. The cause is usually trauma and the typical presentation includes pain, pallor and paresthesia. This condition is regarded as a medical emergency and an early diagnosis with serial examination together with compartment pressure evaluation is necessary. Fasciotomy is the main therapeutic strategy.

    The disease is triggered by the following process: anatomic/foreign. Also this disease is caused by the process: infectious.

    Presentation

    The earliest and most important symptom that occurs in patients with all forms of compartment syndrome, including anterior, is pain, which progresses and becomes more intense over time [13]. Most patients report extreme pain which may be out of proportion to the severity of injury, as the skin overlying the anterior segment ay be intact although under pressure and shows no signs of trauma. Muscle stretching or passive limb movement can exacerbate the pain. In addition to pain, the other symptoms that are encountered include paresthesia, paralysis, pallor and pulselessness, comprising the 5 P's of compartment syndrome. Paresthesia, diminished 2-point discrimination, as well as sensory loss are neurological deficits that are often observed [14], while pale skin overlying the affected compartment is also a hallmark of this condition.

    Skin
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  • psychiatrical
    Suggestibility
    • Suggesting that the intervention reduced the previous intra-compartmental pressure rise associated with activity.[thesportsphysiotherapist.com]
    • Symptoms [ edit ] Diffuse tightness and tenderness over the entire belly of the tibialis anterior that does not respond to elevation or pain medication can be early warning signs and suggestive of Anterior Compartment Syndrome.[en.wikipedia.org]
    • It is suggested that about 69% of those diagnosed with ACS are runners.[kinetic-revolution.com]
    • Pain and a palpably tense and tender compartment suggest the diagnosis.[uptodate.com]
    • […] et al 109 was the first to suggest this using an animal model, with ranges from 10 mmHg to 35 mmHg considered diagnostic. 103,111,112 However, there is now experimental and clinical work suggesting a pressure difference or delta pressure ( P diastolic[boneandjoint.org.uk]
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  • cardiovascular
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  • musculoskeletal
    Muscle Swelling
    • Chronic exertional compartment syndrome (CECS) It is a compartment syndrome - the tibialis anterior muscle swells with exercise producing relative muscle ischaemia as the muscle expansion is restricted by the non expansile fascial compartment - may be[gpnotebook.co.uk]
    • A runner with a chronic or long standing injury may require fasciotomy (which will allow more room for muscle swelling in the anterior compartment).[lifecare.com.au]
    • Compartment syndrome is a condition in the body where the muscles swell and put pressure on the membrane that houses them, or their ‘compartment’.[ezultrasound.com]
    • Because muscles swell up during exercise, muscle compartments are typically large enough to accommodate this swelling.[runnersconnect.net]
    • Compartment syndrome is a condition characterized by a variety of symptoms (such as pain and muscle tightness), which occurs in the lower leg as a result of exercise-induced muscle swelling and a subsequent increase in local tissue pressure.[athleticedge.biz]
    Medial Tibial Stress Syndrome
    • It's also seen regularly in the distal medial region of the leg, where it's called posterior shin splints or medial tibial stress syndrome (MTSS).[massagetoday.com]
    • If conservative treatment does not seem to be beneficial, visit your family physician and rule out other pathologies that are also commonly found in the lower leg, such as tibial stress fractures, tibial periostitis, or medial tibial stress syndrome.[solescience.ca]
    • Shin pain can also be caused by medial tibial stress syndrome (“shin splints”) or a stress fracture, but these cause pain on the shin bone, not deep in the shin muscles.[runnersconnect.net]
    • See separate leaflet called Shin Splints (Medial Tibial Stress Syndrome) for more detail .[patient.info]
    • Consider Bone Scan: Medial Tibial Stress Syndrome demonstrates diffuse moderate increased activity along posteromedial border of tibia.[eorif.com]
    Lower Leg Pain
    • Athletes that present with CECS will complain of increasing lower leg pain upon physical exertion.[thesportsphysiotherapist.com]
    • When lower leg pain begins during exercise (not before), then lingers long after you finish exercising, you may have compartment syndrome.[runnersworld.com]
    • For example, chronic compartment syndromes often develop in military recruits when they begin basic training and their activity levels are drastically increased. 3 Symptoms might include aching lower leg pain, paresthesia, coldness in the feet, color[massagetoday.com]
    • Patients often complain of lower leg pain during exercise and describe it as easing with cessation of activity.[podiatrytoday.com]
    • leg pain that’s present on both sides is more likely to be compartment syndrome, since most other injuries (with the exception of shin splints and occasionally tibial stress fractures) rarely occur on both legs concurrently.[runnersconnect.net]
    Myopathy
    • It is important that the condition is properly diagnosed, to rule out other conditions such as shin splints , deep vein thrombosis, nerve and vascular entrapment syndromes, infections, myopathies and tumours.[rehab4runners.co.uk]
    Muscle Tenderness
    Foot Pain
    • Signs and Symptoms 5 P's: paresthesia (numbness in toes), paresis (drop foot), pain (front of shin bone), pallor (pale area of skin), pulselessness (decreased pulse in foot) Acute: Pain and muscle cramping during and after soccer practice and games Warm[sportmedbc.com]
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  • neurologic
    Tingling
    • If the fascia surrounding the compartment does not stretch enough (remember, the bony walls of the compartment don't give), the increased pressure will compress the artery and nerve, thereby causing pain or numbness or tingling in the distribution of[spinalhealth.net]
    • […] anterior compartment syndrome A condition that typically arises in the anterior compartment of the lower leg, characterised by cramping, pain and tightness, often with numbness and tingling in the foot. anterior compartment syndrome A condition in which[medical-dictionary.thefreedictionary.com]
    • If you experience decreased sensation, numbness or tingling, or sudden muscle weakness after an injury, our doctors encourage you to go the nearest emergency room.[nyulangone.org]
    • Any injury to the lower leg that causes swelling, numbness, burning, or tingling should be looked at carefully, as these symptoms are not typical for other running injuries.[runnersconnect.net]
    • Burning/tingling sensations around the muscle.[themtdc.com]
    Paresthesia
    • The 5 Ps of Anterior Compartment Syndrome: Pain Pallor Paresthesia Pulselessness Paralysis (If not treated) Treatment [ edit ] This section is empty.[en.wikipedia.org]
    • If paresthesia is present, compartment syndrome should be suspected because this is a symptom of nerve involvement and there is no nerve pathology in shin splints.[massagetoday.com]
    • […] features of acute compartment syndrome 1) traumatic onset 2) fascial compartment pressure rises rapidly (within hours) above 40mm hg due to bleeding and mm swelling 3) venous return restricted 4) arterial flow compromised 5) neural tissue compressed paresthesia[quizlet.com]
    • Signs and Symptoms 5 P's: paresthesia (numbness in toes), paresis (drop foot), pain (front of shin bone), pallor (pale area of skin), pulselessness (decreased pulse in foot) Acute: Pain and muscle cramping during and after soccer practice and games Warm[sportmedbc.com]
    • Paresthesias may be present.[epainassist.com]
    Foot Drop
    • In severe cases, foot drop or slapping gait can occur since the individual could not properly lift the foot up when walking.[firstaidcpredmonton.ca]
    • Weakness when trying to pull the foot upwards against resistance which may result in foot drop or a slapping gait.[thewalledcitymarathon.com]
    • drop, in severe cases, if legs are affected Often occurs in the same compartment of both legs Occasionally, swelling or bulging as a result of a muscle hernia Pain due to chronic exertional compartment syndrome typically follows this pattern: Begins[mayoclinic.org]
    • Foot drop when walking and the inability to dorsiflex the toes are tell-tale signs of anterior compartment syndrome of the leg and compression of the deep fibular nerve when associated with the other symptoms described above.[med.umich.edu]
    • Weakness in the foot which may cause foot drop or a slapping gait to occur.[epainassist.com]
    Paresis
    • Clinical examination is of critical importance in reaching a diagnosis: first of all a painful swelling occurs, followed by muscular paresis or paralysis, and finally loss of sensation and a "silent" electromyogram (EMG).[ncbi.nlm.nih.gov]
    • Signs and Symptoms 5 P's: paresthesia (numbness in toes), paresis (drop foot), pain (front of shin bone), pallor (pale area of skin), pulselessness (decreased pulse in foot) Acute: Pain and muscle cramping during and after soccer practice and games Warm[sportmedbc.com]
    • With three positive signs the odds were 93%, however, the third sign was paresis.[boneandjoint.org.uk]
    • Late manifestations of compartment syndrome include the absence of a distal pulse, hypoesthesia, and extremity paresis, because the cycle of elevating tissue pressure eventually compromises arterial blood flow.[emedicine.medscape.com]
    • Of note, muscle weakness or paresis is a late finding of ACS and suggests permanent muscle damage.[uptodate.com]
    Hypesthesia
    • Hypesthesia and painful dysesthesia Prognosis Outcome of compartment syndrome depends on both the diagnosis and the time from injury to intervention.[boneandspine.com]
    • Increased pressure in this compartment may cause plantar hypesthesia, weakness of toe flexion, and pain with passive extension of the toes.[uptodate.com]
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  • Entire body system
    Pain
    • The 5 Ps of Anterior Compartment Syndrome: Pain Pallor Paresthesia Pulselessness Paralysis (If not treated) Treatment [ edit ] This section is empty.[en.wikipedia.org]
    • The pressure builds up inside the sheath causing pain.[return2fitness.co.uk]
    • pain on a 0 to 10 point scale (0 no pain, 10 excruciating pain requiring narcotic analgesics).[consultant360.com]
    • Pain upon flexing the foot and toes downwards.[epainassist.com]
    • Acute compartment syndrome is sudden onset and causes considerable pain.[sportsinjuryclinic.net]
    Swelling
    Physician
    • Only after completely healed with the physician's OK.[sportmedbc.com]
    • Diagnosis [ edit ] If these symptoms are observed/experienced it is important to contact a physician specializing in sports medicine ( MD / DO ), a doctor of podiatric medicine (DPM), or other qualified health care professional immediately so as to get[en.wikipedia.org]
    • Physicians can subsequently treat the condition surgically with a high rate of success.[podiatrytoday.com]
    • CRC Press , 12.11.2003 - 328 Seiten 0 Rezensionen Written by an internationally recognized expert, this book provides a comprehensive text for physicians, nurses, and physiotherapists treating patients with acute and chronic compartment syndromes.[books.google.de]
    • Needle manometry is commonly recommended and will allow the physician to properly diagnose CECS by examining the pressure within the affected compartment.[solescience.ca]
    Disability
    • Chronic anterior compartment syndrome can be a disabling injury which may require a fasciotomy, depending upon the severity and duration of the patient's symptoms and the intracompartmental pressures.[ncbi.nlm.nih.gov]
    • The article is titled “ Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome .”[runblogger.com]
    • Since irreversible tissue changes and permanent disability can occur within a very short time, this condition is reported to be one of the most common causes of medicolegal conflicts, especially when there is inadequate medical documentation, failure[symptoma.com]
    • Discusses physical agents and therapeutic exercise in the prevention, diagnosis, treatment and rehabilitation of disorders that produce pain, impairment, and disability.[books.google.de]
    • Overview Chronic exertional compartment syndrome is an exercise-induced muscle and nerve condition that causes pain, swelling and sometimes disability in the affected muscles of your legs or arms.[mayoclinic.org]
    Pallor
    • The 5 Ps of Anterior Compartment Syndrome: Pain Pallor Paresthesia Pulselessness Paralysis (If not treated) Treatment [ edit ] This section is empty.[en.wikipedia.org]
    • Signs and Symptoms 5 P's: paresthesia (numbness in toes), paresis (drop foot), pain (front of shin bone), pallor (pale area of skin), pulselessness (decreased pulse in foot) Acute: Pain and muscle cramping during and after soccer practice and games Warm[sportmedbc.com]
    • Pulselessness, paralysis, pallor, and parasthesias are all late indicators.[orthobullets.com]
    • These p’s stand for: Pain Pallor Paresthesia Pulselessness Paralysis – if not treated Tenderness and tightness over the total middle of the tibialis anterior which does not react to pain medications and elevation may be early suggestions or signs of this[syndrome.org]
    • […] suspect if: one of the fractures listed above is present one of the soft tissue injuries listed above is present (e.g. crush injury) patient has a coexistent bleeding dosorder or coagulopathy Remember the 6Ps 1. pain (especially on passive stretching) 2. pallor[lifeinthefastlane.com]
    Falling
    • Acute compartment syndrome is brought on by injury or trauma, such as from a fall or a car crash, and is generally a medical emergency.[ezultrasound.com]
    • Caleb knew he would miss his fall baseball season, but was hoping to try out for JV basketball that winter.[moveforwardpt.com]
    • This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player's helmet.[orthoinfo.aaos.org]
    • Average 4.4 of 92 Ratings Technique Guides (2) Questions (22) (OBQ12.28) A 35-year-old male sustains a closed tibial shaft fracture after falling from 12 feet.[orthobullets.com]
    • The normal pressure of a tissue compartment falls between 0 and 8 mmHg.[uptodate.com]
    Burning Pain
    • Symptoms of ACS can include the following: Pain out of proportion to apparent injury (early and common finding) Persistent deep ache or burning pain Paresthesias (onset within approximately 30 minutes to two hours of ACS; suggests ischemic nerve dysfunction[uptodate.com]
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  • Workup

    The diagnosis of ACP almost solely depends on the skill of the physician and the degree of clinical suspicion about this condition. A thorough physical examination should be performed and a detailed patient history should be obtained. Events preceding the development of symptoms and their duration (long standing symptoms are noted in chronic exertional CP), as well as use of anticoagulant medications should be noted. Physical examination can reveal other accompanying findings supporting the diagnosis e.g. signs of trauma. Patients with suspected ACP should be examined several times in a relatively short period to assess potential progression of symptoms and decide on appropriate therapy.

    In addition to physical examination, compartment pressure can be determined using various available techniques. If the ACP occurs in the lower leg, a syringe with a pressure monitor is introduced 1 cm medial to the anterior tibial border into the anterior compartment and pressure measurements obtained. The threshold for abnormally high compartment pressure is controversial, and large-scale studies have determined significant overlap between pressure values of actual patients with control subjects [15]. However, values that are an indication for surgical treatment are either 30 mm Hg below the mean arterial blood pressure or 20 mm Hg below diastolic arterial pressure [16], which indicates that arterial blood pressure should be monitored closely as well. If threshold values are reached, immediate surgical treatment should be performed.

    Additional diagnostic procedures should include various imaging studies, such as plain radiography or CT scan to assess patients with trauma and identify possible bone fractures or other injuries.

    This syndrome can present significant challenges in the diagnostic workup. Since irreversible tissue changes and permanent disability can occur within a very short time, this condition is reported to be one of the most common causes of medicolegal conflicts, especially when there is inadequate medical documentation, failure to conduct serial physical examination as well as follow-up tests [17]. Hence medical personnel should be on a high alert when CS is suspected.

    Pathology

    Other Pathologies
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  • Laboratory

    Serum
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  • Treatment

    When the diagnosis of ACS is based on concrete findings, immediate surgical treatment is indicated for almost all patients [18]. Initial decompression and complete fasciotomy is performed. This comprises of removal of overlying fascia surrounding the compartment. Depending on the severity of trauma, bone reposition or grafting may be performed along with ligation or suturing of blood vessels and debridement of necrotic tissue. In most cases of ACP involving the lower leg, removal of all four fascia is recommended to improve treatment outcomes. Various surgical approaches exist when it comes to management of ACP in the arms and legs and either one or more incisions are made. In some cases, skin grafting may be recommended, so that the effects achieved by fasciotomy are maximized.

    Prognosis

    This condition should be treated as an emergency, as extensive tissue necrosis and irreversible injury can occur if it is not diagnosed and treated early. With early therapy patients have an excellent prognosis [11], and only a minority of patients may have residual complaints. Without treatment, however, the condition may result in paralysis, or in some cases, limb amputation. Some studies have established that almost 75% of limb amputations occurred because of delayed treatment or incomplete fasciotomy [12].

    Complications

    Deep Vein Thrombosis
    • Your recognised location is United States (US Deep vein thrombosis This article is freely available only to users in the UK.[evidence.nhs.uk]
    • It is important that the condition is properly diagnosed, to rule out other conditions such as shin splints , deep vein thrombosis, nerve and vascular entrapment syndromes, infections, myopathies and tumours.[rehab4runners.co.uk]
    • DVT stands for Deep Vein Thrombosis, which is a blood clot.[tendonitisexpert.com]
    • Anticoagulation following surgery, such as prophylaxis against deep vein thrombosis, may contribute to ACS [ 31 ].[uptodate.com]
    • Pneumatic intermittent calf-compression devices and thromboembolic deterrent stockings were applied bilaterally throughout the procedure to prevent deep vein thrombosis.[pubmedcentralcanada.ca]
    Necrotizing Fasciitis
    • Trauma-related indications for HBO therapy include carbon monoxide intoxication, gas gangrene, crush injury, compartment syndrome, necrotizing fasciitis, treatment of chronic osteomyelitis, support of grafts and flaps, and burns.[orthobullets.com]
    Compartment Syndrome
    • The anterior compartment syndrome of the lower leg (often referred to simply as anterior compartment syndrome), can affect any and all four muscles of that compartment: tibialis anterior , extensor hallucis longus , extensor digitorum longus , and peroneus[en.wikipedia.org]
    • Compartment Syndrome Causes Acute compartment syndrome is the most common type of compartment syndrome.[webmd.com]
    • Acute Compartment Syndrome Acute compartment syndrome is a surgical emergency.[orthoinfo.aaos.org]
    Anterior Tibial Compartment Syndrome
    • The anterior (tibial) compartment syndrome, also called anterior or lateral shin splints, usually occurs when a runner changes from a flatfooted to a toe-running style, begins interval training on a track or hill, or runs in a shoe with a sole that is[lifecare.com.au]
    • Tibial Compartment Syndrome: - complication of open / closed frx; - also w/ prolonged excersise and hemorrhage; - prolonged ischemia may cause muscle ischemia and myonecrosis; - deep Peroneal Nerve may be damage by increased pressure or by decreased[wheelessonline.com]
    • Bilateral Anterior Tibial Compartment Syndrome Following Burn of Lower Extremities (Author's Transl) M Berky et al.[ncbi.nlm.nih.gov]
    • tibial compartment syndrome Anterior tibial syndrome Nontraumatic compartment syndrome of leg Nontraumatic compartment syndrome of lower extremity ICD-10-CM M79.A29 is grouped within Diagnostic Related Group(s) (MS-DRG v 35.0): 557 Tendonitis, myositis[icd10data.com]
    • The anterior tibial compartment syndrome.[boneandjoint.org.uk]
    Paralysis
    • Paralysis of this muscle would indicate deep fibular nerve injury.[med.umich.edu]
    • The 5 Ps of Anterior Compartment Syndrome: Pain Pallor Paresthesia Pulselessness Paralysis (If not treated) Treatment [ edit ] This section is empty.[en.wikipedia.org]
    • Clinical examination is of critical importance in reaching a diagnosis: first of all a painful swelling occurs, followed by muscular paresis or paralysis, and finally loss of sensation and a "silent" electromyogram (EMG).[ncbi.nlm.nih.gov]
    • Pulselessness, paralysis, pallor, and parasthesias are all late indicators.[orthobullets.com]
    • Symptoms of advanced acute compartment syndrome can include numbness or paralysis.[healthline.com]
    Neoplasm
    • […] the puerperium ( O00-O9A ) congenital malformations, deformations, and chromosomal abnormalities ( Q00-Q99 ) endocrine, nutritional and metabolic diseases ( E00 - E88 ) injury, poisoning and certain other consequences of external causes ( S00-T88 ) neoplasms[icd10data.com]
    Edema
    • Resultant tissue ischemia further worsens edema in a vicious circle.[merckmanuals.com]
    • It presents in-depth coverage of acute and chronic compartment syndromes, considerations of interstitial space, intramuscular pressure recordings, and limb edema.[books.google.de]
    • Compartment syndrome can develop from the fracture itself, due to pressure from bleeding and edema.[webmd.com]
    • It may result from bleeding into the compartment space or due to accumulation of fluid (edema).[docpods.com]
    • As the intracompartmental tissue increases in pressure there is a decrease in tissue perfusion and this leads to muscle ischemia and subsequently cell edema.[orthopaedicsone.com]
    Stress
    • The problem is often the result of repetitive stress.[runnersworld.com]
    • Shin pain can also be caused by medial tibial stress syndrome (“shin splints”) or a stress fracture, but these cause pain on the shin bone, not deep in the shin muscles.[runnersconnect.net]
    • Address the causes In part one of this blog we looked at how certain factors can place greater stress on parts of the bone leading to stress reaction and eventually, if continued, stress fracture.[running-physio.com]
    • If conservative treatment does not seem to be beneficial, visit your family physician and rule out other pathologies that are also commonly found in the lower leg, such as tibial stress fractures, tibial periostitis, or medial tibial stress syndrome.[solescience.ca]
    • It is important, not to attempt to "play through" the pain or place continual pressure on a stress fracture, as a complete fracture of the weakened bone may result.[sportmedbc.com]

    Etiology

    The causes of anterior compartment syndrome may be divided into those causing acute and those causing chronic or exertional forms of the syndrome. Trauma is the most common cause of acute compartment syndrome and includes injuries from motor vehicle accidents, fractures, contusions or crush injuries [3]. Acute CS can occur after surgical repair of vascular injury. This is associated with reestablishment of blood flow and subsequent increase in local pressure. Prolonged limb immobilization by casts or bandages can also cause increase in local pressure. On the other hand, chronic forms of CS is seen in athletes, in whom prolonged activity leads to compression of local tissues with strenuous muscle activity. Muscle hypertrophy can also be a contributing factor to its development [4].

    The anterior compartments of the body that may be affected include:

    • Lower leg - Includes tibialis anterior, extensor hallucis longus and extensor digitorum longus muscles, the tibial artery and vein and the deep peroneal nerve.
    • Thigh - Contains sartorius and all four parts of the quadriceps muscle, together with the femoral artery and nerve.
    • Arm - Biceps brachii, brachialis and coracobrachialis comprise the muscular components of the anterior compartment of the arm, together with the brachial artery and the musculocutaneous nerve.
    • Forearm - Contains 8 muscles, 5 in the superficial layer (flexor carpi radialis, flexor carpi ulnaris, flexor digitorum pronator teres and palmaris longus) and three in the deep layer (flexor digitorum profundus, flexor pollicis longus and pronator quadratus), while the nerves that pass through the anterior compartment include the anterior interosseus nerve (a branch of median nerve) and ulnar nerve.

    Causes

    Epidemiology

    Data regarding the incidence and prevalence of CS is significantly related to traumatic events, since the vast majority of cases occur under these circumstances. Prevalence rates of CS in terms of specific compartments currently do not exist. It is estimated that around 18% of all tibial fractures eventually progress to CS, with virtually all requiring surgical treatment [5]. Other studies found an incidence of only 1.2% for similar type of injury [6]. CS is estimated to occur in approximately 6% of all foot injuries following motorcycle accidents [7]. Regarding chronic forms of CS, about 14% of patients who had lower leg pain due to unknown cause were found to have chronic CS [8].

    Sex distribution
    Age distribution

    Pathophysiology

    The pathogenesis of ACS starts with alterations in normal blood flow, usually as a result of trauma. Several theories exist regarding the initial events that occur after trauma, but vessel injury leads to extravasation of blood into the interstitium, leading to edema [9]. Continuous pooling of blood and fluid in the interstitium occurs because of increased capillary permeability as well, since it is stimulated by sudden oxygen deprivation of local tissue. Once the interstitial pressure exceeds the diastolic pressure, tissue perfusion is affected adversely. In an attempt to provide oxygen and nutrients to ischemic and hypoxic tissues, the circulatory system further increases the permeability of capillaries. However, this creates a vicious cycle and eventually leads to severe acidosis and ischemia.

    Initially, it was established that 5-6 hours are sufficient for development of irreversible muscle damage, but recent experiments have shown that as little as 3 hours are sufficient to cause significant damage [10]. Because of extensive muscle necrosis, significant amounts of myoglobin are released and may rapidly cause kidney injury. For these reasons, clinical suspicion and an early diagnosis may lead to significantly better patient outcomes.

    Prevention

    Because the majority of events that trigger this condition are unexpected, prevention is rarely possible. However, in case of chronic exertional compartment syndrome affecting the anterior segment, with recurrent pain, an early diagnosis may significantly reduce the amount of damage to local tissues.

    Summary

    Compartment syndrome (CP) is a term that describes pressure changes in various compartments leading to extensive tissue necrosis and irreversible injury to local structures. Anterior compartment syndrome (ACP) implies that this condition occurs within the anterior compartments of the body. The lower leg is most commonly affected. The anterior compartment in the leg includes tibialis anterior, extensor hallucis longus and extensor digitorum longus muscles, both tibial artery and vein and the deep peroneal nerve. Anterior compartments of the thigh, arm and forearm can also be affected [1], while some compartments of the hand and foot could be potentially classified into this group of disorders as well. ACP can be either acute or chronic and different causes are responsible for the two forms. Acute ACP is in most cases caused by trauma, including fractures and motor vehicle accidents, while the chronic form is primarily seen in athletes, in which persistent repetitive muscle activity leads to intracompartmental pressure elevation [2]. This form is also known as chronic exertional compartment syndrome and is most commonly seen in runners with lower leg involvement. Certain predisposing factors have been identified, such as muscle hypertrophy, concomitant bleeding disorders and use of anticoagulant therapy. Although the exact mechanism of how CP occurs is unknown, the presumable theory is that the increase in intracompartmental pressure results from bleeding and consequent edema, which results either from indirect vascular injury or from increased permeability of the capillaries due to oxygen deprivation. In either case, a vicious cycle of ischemia and tissue hypoxia occurs, which leads to acidosis and severe tissue necrosis within hours after onset. Because irreversible tissue injury can occur within a few hours, an early diagnosis can prevent permanent damage and even limb amputation in some cases, which is why attending physicians should always exclude this condition during physical examination and workup. The initial presentation of ACP is severe pain, accompanied by pallor of the overlying skin. Neurological deficits, including sensory loss and paresthesia are often present. Patient history is a vital component of the diagnostic workup and information regarding recent trauma or other factors that can provoke ACP may provide significant clues. The diagnosis is based on clinical grounds, with serial examinations, along with invasive measurement of compartment pressures to confirm the diagnosis. Treatment principles include fasciotomy of the affected compartment, together with other necessary measures. This condition should be considered a medical emergency and the time of initiation of therapy significantly influences patient outcomes.

    Patient Information

    Anterior compartment syndrome is a condition that implies very large sudden increase in pressures of certain parts of the body,leading to extensive tissue damage. For this reason, it is considered to be a medical emergency. Virtually all muscles in the body are, along with the accompanying blood vessels and nerves, are grouped into "compartments" which are created by a layer of connective tissue called the fascia. This tightly encloses the muscles and vessels. In the setting of trauma, which is the most common cause of this syndrome, injury to blood vessels leads to bleeding into the compartment in which the vessel is located. This results in swelling followed by increase in pressure. This pressure disables normal oxygen and nutrient transport to desired tissues, leading to hypoxia and cell death if left untreated. In the case of anterior compartment syndrome, the anterior (or front) compartments can be affected, specifically the front portions of the arm, forearm, thigh and lower leg. In addition to trauma, other factors may predispose individuals to this condition, such as use of anticoagulant drugs, immobilization due to previous trauma with casts or splints and certain surgical procedures that involve restoration of blood flow. A particular form of this syndrome, called chronic exertional compartment syndrome is seen most commonly in athletes who run. This includes recurrent development of symptoms after vigorous muscle exercise. The initial presentation of patients starts with appearance of severe pain at the site of injury, and becomes progressively worse. In addition to pain, symptoms include reduced sensation, pale skin overlying the affected compartment, while paralysis may ensue if treatment is delayed. The diagnosis of anterior compartment syndrome needs to be performed urgently and almost exclusively relies on the ability of the physician to clinically recognize the condition. Since irreversible injury may occur within hours of onset, an initial diagnosis can be made after series of physical examinations performed in a short period of time. Patients may provide significant information such as recent trauma or history of similar symptoms which may further support the diagnosis. To confirm the diagnosis, a syringe is introduced into the affected compartment to measure compartment pressure. Once the diagnosis is established, immediate surgical treatment is indicated. It comprises of removal of fascia that covers the affected compartment. This procedure is known as fasciotomy. Improper or delay in treatment may lead to paralysis and even limb amputation as a result of severe and irreversible muscle damage. This condition should be suspected in all patients who experience recent trauma and complain of severe localized pain.

    Other symptoms

    Anterior Compartment Syndrome
    • The anterior compartment syndrome of the lower leg (often referred to simply as anterior compartment syndrome), can affect any and all four muscles of that compartment: tibialis anterior , extensor hallucis longus , extensor digitorum longus , and peroneus[en.wikipedia.org]
    • Descriptor ID D000868 MeSH Number(s) C05.651.180.063 C14.907.303.063 Concept/Terms Anterior Compartment Syndrome Anterior Compartment Syndrome Anterior Compartment Syndromes Compartment Syndrome, Anterior Compartment Syndromes, Anterior Syndrome, Anterior[profiles.umassmed.edu]
    Ischemia
    • Resultant tissue ischemia further worsens edema in a vicious circle.[merckmanuals.com]
    • […] may cause muscle ischemia and myonecrosis; - deep Peroneal Nerve may be damage by increased pressure or by decreased blood supply to the nerve Chronic anterior-compartment syndrome of the leg.[wheelessonline.com]
    • The resultant ischemia leads to necrosis (death of tissue) of the muscles and nerves.[en.wikipedia.org]
    • With late diagnosis, irreversible tissue ischemia can develop in the acute setting.[emedicine.medscape.com]
    • Ischemia occurs when tissue pressures approach diastolic pressure [ 77,78 ].[uptodate.com]
    Muscular Dystrophy
    • Dystrophy Nausea Neck Injury Neck Training Neuromuscular Training New Client Orientation Nutrition Nutrition Coaching Obesity Olympic Lifting Organic Food Orthotics Osgood-Schlatter Osteoarthritis Osteoporosis Outdoor Training Overheating Overtraining[ptonthenet.com]
    Hypersensitivity
    • However, approximately 3% to 17% of people who have undergone a fasciotomy experience less than favorable outcomes such as ankle pain, decreased sensation at the incision site, numbness at the lateral lower leg, hypersensitivity to touch, paresthesia[thesportsphysiotherapist.com]

    Self-assessment

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    References

    1. Chandraprakasam T, Kumar RA. Acute compartment syndrome of forearm and hand. Indian J Plast Surg. 2011;44(2):212-218.
    2. Piasecki DP, Meyer D, Bach BR Jr. Exertional compartment syndrome of the forearm in an elite flatwater sprint kayaker. Am J Sports Med. 2008;36(11):2222-2225.
    3. Mithofer K, Lhowe DW, Vrahas MS, Altman DT, Altman GT. Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries. Clin Orthop Relat Res. 2004;223–229.
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    • ENTODERMAL CYST ASSOCIATED WITH AXIAL DEFORMITIES: A CASE SHOWING THE" ENTODERMAL-ECTODERMAL ADHESION SYNDROME" - N Prop, EL Frensdorf, FR Van de Stadt - Pediatrics, 1967 - Am Acad Pediatrics
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