Lower Leg

 Four Fascial Compartments

 Anterior
 Lateral
 Superficial posterior
 Deep posterior

07/18/09 1
 Anterior

 Tibialis anterior
 Extensor digitorum longus
 Extensor hallicus
 Deep peroneal nerve
 Anterior tibial artery and vein

07/18/09 2
 Lateral

 Peroneus longus
 Peroneus brevis
 Superficial peroneal nerve

07/18/09 3
 Superficial Posterior

 Soleus
 Gastrocnemius
 Tendons of the plantaris

07/18/09 4
 Deep Posterior

 Flexor digitorum
 Flexor hallicus longus
 Tibialis posterior
 Peroneal and posterior tibial artery and vein
 Tibial nerve

07/18/09 5
 Compartment Muscles
 Anterior
 Extensors
 Shock absorbers
 Lateral
 Evertors
 Superficial Posterior
 Plantar flexors
 Deep Posterior
 Invertors
 Stabilizers overpronation

07/18/09 6
 Shin Splints
 Tendinitis
 Periostitis
 Muscle strain
 Interosseus membrane strain

07/18/09 7
 Types of Shin Splints

 Anterior
 Tibialis anterior
 Extensor hallucis longus
 Extensor digitorum longus
 Posterior
 Tibialis posterior
 Flexor hallucis longus
 Flexor digitorum longus

07/18/09 8
 Presentation

 Pain is often at the middle or lower third of

tibia.
 Anterior
 Lateral to the middle tibia.
 Posterior
 Posteromedial to the middle or lower tibia.

07/18/09 9
 Treatment
 Acute
 Rest
 Ice
 Support – elastic tape
 Support at the foot – taping and/or medial
heel wedges.
 Orthotics – recurrent/chronic
 Calcium – one study

07/18/09 10
 Compartment Syndrome
 Presentation
 Most common is the athlete/exercise.
 Complains of aching or cramping of leg following
exercise.
 Pain is relieved by rest initially.
 Numbness/paresthesia may be present into parts of the
foot, in the distribution of the corresponding nerve.
 Local trauma or fracture may also result in this syndrome.
 Fascial defects with muscle herniations are present in
~ 40% of patients.

07/18/09 11
 Etiologies for Pressure in
Compartments
 Patients who have crush injuries or fractures with marked
swelling are at risk for developing ACS.
 Patients who have had reduction of long-bone fractures and
those who have experienced prolonged external pressure
from pneumatic antishock garments, casts, or tight-fitting or
blood-soaked dressings.
 ACS occurs when the function of muscles, blood vessels,
and nerves is jeopardized by the pressure within the layers
of semirigid fascia that support and partition them.

07/18/09 12
 Pathophysiology of Compartment
Syndrome
 After an injury to an extremity, an immediate inflammatory
response results in decreased blood flow distal to the injury
and tissue hypoxia.
 Inflammatory mediators are released and cause the capillary
wall to lose integrity and colloid proteins to leach into the
soft tissue, drawing more fluid into the soft tissue.
 This fluid shift causes increased edema, and the cycle is
perpetuated.
 The imbalance in pressures between inflow of arterial blood
and outflow of venous blood eventually culminates in total
cessation of blood flow into the affected extremity.

07/18/09 13
 Compartmental Pressures
 Intracompartmental pressures in excess of 30 to 40 mm Hg can cause
muscle ischemia; pressure greater than 55 to 65 mm Hg causes irreversible
muscle death.
 Normal pressure within a compartment is 8 mm Hg or less.
Even within four to six hours of the onset of ACS, a patient may develop
irreversible muscular damage.
 ACS sequelae can run the gamut from foot drop due to peroneal nerve
injury to something as severe as a completely insensate, nonfunctional
extremity with muscle fibrosis and joint contracture (Volkmann's ischemic
contracture).
 Potential systemic complications include myoglobinuria, which can lead to
renal failure, and untreated infection of an extremity, leading to sepsis.
 In a worst-case scenario, a patient may require amputation.

07/18/09 14
 Evaluation

 Symptoms usually occur within 10-30

minutes of exercise.
 Pain will subside over minutes or hours
following activity.
 Pulses are often normal distally.
 Examination is often normal between
exacerbations.

07/18/09 15
 Signs of ACS

 The key signs and symptoms of ACS can be

summed up by the "six P's.“
 Pain
 Paresthesia
 Pressure
 Pallor
 Paralysis
 Pulselessness

07/18/09 16
 Pain
 Is a crucial, though not specific, early sign.
 Red flags include:
 Patient's complaint of diffuse pain that's not relieved by
analgesics
 Pain that's greater during passive motion rather than
during active motion.
 Severe pain that's out of proportion to the injury.

07/18/09 17
 Paresthesia
 Abnormal sensations such as burning, may be the
first symptom to appear, as nerves are very
sensitive to pressure.

07/18/09 18
 Pressure
 Refers to tension felt during palpation.
 As compartment pressure rises, the affected area
becomes extremely taut and feels firm to the touch.

07/18/09 19
 Pallor
 Caused by pressure in the compartments that
suffered arterial injury, is a late and ominous sign.

07/18/09 20
 Paralysis
 Is usually a late symptom.
 It is caused by either prolonged nerve compression
or irreversible muscle damage.

07/18/09 21
 Pulselessness
 Is a late and ominous sign, indicating death of
tissue.
 A pulse is present in the limb until the very late
stages.

07/18/09 22
 Patient Assessment
 Compare the injured limb with the non-injured limb at least every one to
two hours, or more frequently depending on the patient's status and the
physician's orders.
 Prompt recognition and intervention are essential.
 If you suspect ACS, the physician will need to measure the compartment
pressure by inserting a needle, wick, or slit catheter into the
compartment.
 Depending on the reading, a surgeon may need to perform a fasciotomy
—an incision into the fascia of the affected compartment to relieve the
pressure and restore circulation.
 Precisely how high a reading merits a fasciotomy is controversial.

Some clinicians will do a fasciotomy if the compartment pressure is

33 mm Hg; more conservative clinicians might do one only if the
reading hits 60 mm Hg.
07/18/09 23
 Management
 Acute
 Conservative care
• If patient does not respond to conservative care,
fasciotomy is the treatment of choice.
 Chronic
 Rest for 4 to 8 weeks.

07/18/09 24