DEFINITION

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is usually due to trauma to, or reperfusion of, the extremity. Chronic exertional compartment syndrome (CECS) is often 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 Mavor16 was the first to successfully treat a patient with anterior compartment syndrome of the leg using a fasciotomy.

Clinical manifestations of compartment syndrome include exercise-induced pain relieved by rest, swelling, numbness, and weakness of the extremity.8,23

The reported incidence ranges between 14% and 33% among individuals with lower leg pain.3,21,30

 

 

 

FIG 1 • Cross-sectional anatomy of the leg.

 

 

 

CECS is often bilateral and is equally prevalent among males and females. Diabetic patients may be at increased risk of developing CECS.6

 

Case reports of CECS of the forearm, thigh, and gluteal regions exist but are rare.10,12,13,25

 

The leg is the most common site, with the anterior and lateral compartments most frequently affected. Although this chapter focuses on CECS of the leg, the clinical features, diagnostic strategy, and treatment methods are similar for all locations.

 

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, interosseous membrane, anterior intermuscular septum, and deep fascia of the leg.

 

 

The lateral compartment contains the superficial peroneal nerve and two muscles (peroneus longus and

 

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peroneus brevis). Its borders are the anterior intermuscular septum, the fibula, the posterior intermuscular septum, and the deep fascia.

 

 

The common peroneal nerve branches into the s uperficial 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, whereas the deep peroneal nerve wraps around the fibula deep to the extensor digitorum longus until reaching the anterior surface of the interosseous 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 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 interosseous membrane and posteriorly by the deep transverse fascia.

 

A fifth compartment that encloses the tibialis posterior muscle has been described,4 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.11

 

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.

 

 

One study demonstrated a 20% increase in muscle volume during exercise.15

 

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.21

 

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.9,31

 

 

 

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 they can entrap the superficial peroneal nerve exiting the junction of the middle and distal thirds of the leg (FIG 2).

 

Evidence suggests that patients with CECS have a lower capillary density in relation to muscle fiber size compared to controls. This decreased capillarity leads to decreased structural capacity for muscle blood flow.7

 

None of the existing theories explain all of 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 long-standing and recurrent because patients tend to self-limit before subsequently attempting 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 extremity

 

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A transient foot drop 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 the following:

 

Tightness or tenderness to palpation 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 sign over the defect if the superficial peroneal nerve is compressed

 

Numbness and/or motor weakness may be present in the superficial peroneal, deep peroneal, or tibial nerve distributions.

 

When the history and physical examination findings are consistent with CECS, the diagnosis should be confirmed with pre- and postexercise compartment pressure measurements.

 

 

Most clinicians follow the diagnostic criteria of Pedowitz et al,20 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 result in a false-negative result.

 

Several methods for measuring compartment pressures have been described in the literature.

 

 

These include the slit catheter, wick catheter, needle manometry, digital pressure monitor, microcapillary infusion, and solid-state transducer intracompartmental catheter methods.1,2,17,18,25,31

 

The Stryker Intra-Compartmental Pressure Monitor ( Kalamazoo, MI) is a handheld digital monitor that can be used to check multiple compartments. It can be used either with a side port needle or 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.32 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.

 

Ultrasound may play a role in diagnosis by identifying anterior compartment thickness.22

 

Tingling, numbness, or a positive Tinel sign at a specific location may warrant an electromyogram (EMG) and nerve conduction velocity (NCV) studies to evaluate for peripheral nerve entrapment.

 

Pain and coolness with paradoxical claudication may warrant an angiogram to evaluate for popliteal artery 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 or cessation.

 

 

Adjuncts to activity modification include anti-inflammatory medications, stretching, and foot orthotics.

 

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 all affected compartments.

 

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 posteromedial approach offers easier access to the superficial and deep posterior compartments.

 

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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 have been demonstrated.14,34

 

A technique using balloon dissectors and carbon dioxide insufflation is described in the Techniques section.34,35

 

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 through the fascia, and the septum and 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).

 

 

 

 

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.

 

 

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.

 

 

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• 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 junctions 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 junctions 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 toward the midline to minimize risk of injuring cutaneous sensory nerves in the lateral aspect of the compartment.

   

  The distal aspect of the lateral compartment fasciotomy should be directed 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.

   

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• 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 is retracted 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 widened if 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.

   

   

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  TECH FIG 4 • Medial approach. A. An 8- to 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).

 

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 (TECH FIG 5A).

 

Dissection is carried down through the subcutaneous fat and superficial fascia until the deep fascia overlying the muscle is visualized (TECH FIG 5B).

 

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 (TECH FIG 5C).

 

The sheath is removed and the balloon is inflated to create a cavity within the fascial cleft (TECH FIG 5D).

 

The balloon is then deflated and removed.

 

 

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The optical cavity is maintained using towel clips (TECH FIG 5E).

 

Alternatively, the optical cavity between the superficial and deep fascial layers can be maintained 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.

 

A one-way cone-shaped cannula is inserted in the skin at the site of balloon insertion.

 

Next, the fascia overlying the anterior compartment is released with endoscopic scissors down to the level of the ankle under direct vision (TECH FIG 5F).

 

The intermuscular septum between the anterior and lateral compartments, as well as the superficial peroneal nerve, can be visualized (TECH FIG 5G).

 

 

 

TECH FIG 5 • Sequential demonstration of balloon placement in the lower extremity. A. A transverse incision at the anterolateral aspect of the knee between the fibular head and Gerdy's tubercle is used. B. Dissection is carried out to the level of the deep fascia. C. Entry of balloon to the level of the ankle under direct visualization. D. The balloon is inflated. E. Towel clips are used to maintain the visual cavity. (continued)

 

 

If a lateral compartment release is indicated, perform a second fasciotomy posterior to the intermuscular septum.

 

If posterior compartment releases are indicated, make a 2-cm transverse incision proximally along the medial aspect of the leg just posterior to the edge of the tibia.

 

The balloon dissector and sheath are inserted into the fascial cleft overlying the superficial and deep posterior compartments to the level of the ankle.

 

As described earlier, the balloon is inflated, deflated, and removed. Towel clips are used to maintain the cavity.

 

The fascia of the deep posterior compartment is released directly off the posteromedial border of the

tibia, anterior to the intermuscular septum, from proximal to distal under direct visualization with endoscopic scissors.

 

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TECH FIG 5 • (continued) F. The anterior compartment fascia is visualized and released with endoscopic scissors. G. Anterior compartment release in a left leg. The black arrow denotes the intermuscular septum between the anterior and lateral compartments. The white arrow points to the superficial peroneal nerve exiting the fascia of the lateral compartment distally. H. Endoscopic visualization of the posterior fascia of a left leg. I. The black arrow points to the deep posterior release directly off the tibia. The white arrow denotes the superficial compartment release.

 

 

The fascia of the superficial posterior compartment posterior to the intermuscular septum is released in the same fashion (TECH FIG 5H,I).

 

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.

 

PEARLS AND PITFALLS
		Superficial	Identify the nerve as it exits the fascia at the junction of the distal and middle

Incomplete

fascial release

• Muscle herniates at the bottom of the “V” of the fasciotomy, resulting in pain.

Extend lateral and anterior fasciotomies to 4-6 cm above the ankle and posterior fasciotomies to 8-10 cm above the ankle.

Saphenous ▪ Identify the structures in the subcutaneous tissue at the medial aspect of the leg. vein and Avoid excessive traction on the saphenous nerve, which results in a traction nerve injury paresthesia.

thirds of the leg; direct the anterior fasciotomy medially and the lateral fasciotomy

posteriorly at the distal extent.

peroneal

nerve injury

 

 

 

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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 78% to 100%.5,9,19,20,24,26,28,30,33,34

These techniques include open fasciotomies, one- or twoincision minimally invasive subcutaneous fasciotomies, and fasciotomies with partial fasciectomies.

Adequate long-term follow-up is lacking in the literature.

 

Slimmon et al29 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.

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.4,24,26

 

COMPLICATIONS

Recurrence rates of 3% to 17% have been reported after fasciotomy.5,24,26,28

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.27

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.5,9,29,34

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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