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This case report of an acute exertional compartment syndrome involving predominantly the superficial posterior compartment emphasizes several important facts: (1) The subacute recurring syndromes, if left untreated, may develop into an acute syndrome. (2) The diagnostic findings separating the acute syndrome from the chronic forms are marked pain with passive stretch of the involved muscles, paresis, and sensory deficit.8,12,15, (3) In the acute form, immediate fasciotomy is mandatory and often results in full recovery. (4) All four major compartments of the leg are susceptible to chronic or acute compartment syndromes initiated by exertion. These compartments can be decompressed as necessary through a limited skin incision as recently reported.11 (5) The need for an easily obtainable and reproducible method for measuring intracompartment pressures (e.g., the wick catheter technique) is indicated.
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PMID:Acute exertional superficial posterior compartment syndrome. 70 88

The Anterior Compartment Syndrome is a relatively rare affection with a wide spectrum of etiologies. Like every compartment syndrome, it is a condition in which high pressure in a rigid osteofascial space reduces capillary blood perfusion so that tissue viability is threatened. When pressure remains sufficiently high for a number of hours, normal muscle and nerve functions become disturbed which may lead to myoneural necrosis. Therefore, an early decompression by means of fasciotomy is essential. 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). In some cases pressure measurements are necessary, in which tissue pressures over 30 to 40 mm Hg are considered abnormal. The EMG-examination is useful in order to achieve a diagnosis and to assess the degree of injury. It may be an important guide for further rehabilitation.
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PMID:The anterior compartment syndrome in the lower leg. Review and role of the EMG examination. 209 62

Eighteen patients whose mean age was 61 years were referred to us with acute aortic occlusion from 1977 to 1985. Ten patients had cardiac emboli (group I) and eight had aortoiliac occlusive disease (group II). Fourteen of these patients had paresis or paralysis. Diagnosis was prompt but the time lapse from onset of symptoms to revascularization averaged 18 hours (group I, 10.3 hours; group II, 26.1 hours). All 10 patients in group I had embolectomy alone; of the eight patients in group II, two had transfemoral thrombectomy and six had bypass procedures. The perioperative mortality rate was 40% in group I and 62.5% in group II. Complications developed in 12 patients (nine died); renal failure occurred in 11, compartment syndrome in nine, adult respiratory disease syndrome in three, acute myocardial infarction in three, disseminated intravascular coagulation in two, and paraplegia in one. No amputations were required in the nine survivors and limb function was restored in eight of these patients. Acute aortic occlusion sets in motion a chain of events that threatens life and limb. Prompt diagnosis and revascularization by the simplest operation are required to decrease morbidity and mortality.
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PMID:Acute aortic occlusion--a multifaceted catastrophe. 374 30

Fibrotic contracture of skeletal muscle can follow weeks or months after the severe ischemic insult of compartment syndrome. Commonly known as Volkmann's ischemic contracture, the affected limb often becomes dysfunctional and painful, and may lose sensibility. The pathogenesis of the muscle contracture includes prolonged ischemia, myonecrosis, fibroblastic proliferation, contraction of the cicatrix, and myotendinous adhesion formation. Resultant shortening or overpull of involved muscles leads to stiffness and deformity. Simultaneously, nerve injury from initial ischemia or subsequent soft tissue fibrotic compression leads to muscle paresis or paralysis of the involved compartment and of those muscles more distally innervated. The resultant deformity is thus a combination of varying degrees of contracture and weakness depending on which muscles and nerves are affected. Deformity and functional impairment in the foot and ankle secondary to ischemia are determined by many factors, including: (1) which leg compartment, if any, has been affected and to what degree extrinsic flexor or extensor overpull is exhibited, (2) degree of nerve injury sustained causing weakness or paralysis of extrinsic or intrinsic foot and ankle muscles (3) which foot compartment, if any, has been affected and to what degree intrinsic overpull is exhibited, and (4) degree of sensory nerve injury leading to anesthesia, hypoesthesia, or hyperesthesia of the foot. Therefore, a variety of clinical presentations can be encountered following compartment syndrome of the leg and foot. Treatment is based on an appreciation of the pathoanatomy of the deformity. Nonoperative therapy is aimed at obtaining or preserving joint mobility, increasing strength, and providing corrective bracing and accommodative footwear. Operative management is usually reserved for treatment of residual nerve compression or severe and problematic deformities. Established surgical protocols are performed in a stepwise fashion, to include: (1) release of residual or secondary nerve compression, (2) release of fixed contractures, using infarct excision, myotendinous lengthening, muscle recession, or tenotomy, (3) tendon transfers or arthrodesis to increase function, and (4) ostectomy or amputation for severe, refractory deformities.
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PMID:Volkmann's ischemic contracture of the foot and ankle: evaluation and treatment of established deformity. 755 Sep 46

We report two cases of compartment syndrome of the lower leg that occurred in male patients aged 62 and 57 years, respectively, after 10 and 12-h urological surgery in the lithotomy position. During sedation and mechanical ventilation creatine kinase (CK) activity of more than 8,000 U/l was found in both patients. After extubation, clinical symptoms of the compartment syndrome were found. On the 1st day after surgery patient 2 underwent fasciotomy of both lower legs (Fig. 2). No lasting neurologic defects were observed. Patient 1 was treated by fasciotomy on the 4th postoperative day after paresis of the peroneal nerve had developed in the left lower leg. This paresis had shown no tendency to regression when the patient left hospital. On phlebography, both patients showed blockage of the deep lower leg veins up to the knee. DISCUSSION. The compartment syndrome is a rare but serious complication resulting from prolonged surgery in the lithotomy position. Symptoms are neuromuscular lesions of the affected limb. Severe complications of the compartment syndrome are acute renal failure resulting from myoglobin residues in the tubules, electrolyte disturbances, and disorders of acid-base balance. A decrease in perfusion due to the elevated position of the legs, on the one hand, and the impeded venous back-flow due to the positioning on the other are discussed. While positioning the legs, it is important to ensure that the lower legs are lifted only slightly above left atrial level. When rehabdomyolysis occurs, serum CK activity increases. CK values of over 2,000 U/l after surgery may be considered a warning sign in ventilated and sedated patients, in whom early clinical symptoms of the compartment syndrome such as pain and paresthesias cannot be ascertained. Frequent and regular checks of these parameters starting shortly after surgery are recommended. A thorough examination of the lower legs and, if necessary, measurement of the tissue pressure in the compartment should follow. The deep veins of the legs should be checked by phlebography. In cases of verified compartment syndrome, early fasciotomy is the best choice of therapy, because neuromuscular defects are known to be irreversible after 12 to 24 h. Enforced diuresis is recommended in order to avoid renal complications.
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PMID:[Postoperative bilateral compartment syndrome resulting from prolonged urological surgery in lithotomy position. Serum creatine kinase activity (CK) as a warning signal in sedated, artificially respirated patients]. 769 79

Compartment syndrome is a serious potential complication of trauma to the extremities. Fractures, crush injuries, burns, and arterial injuries, among others, can result in increased tissue pressure within closed osseofascial or compartmental spaces. Prolonged exposure to elevated pressure can result in nerve and muscle necrosis. Extreme pain unrelieved with analgesia, subjective complaint of pressure, pain with passive muscle stretching, paresis, paresthesia, and intact pulses, in the presence of a physically tight compartment, should alert the physician to the presence of a compartment syndrome. The diagnosis is a clinical one, but it may be aided by measurements of intracompartmental tissue pressures. Compartment syndrome is a surgical emergency requiring prompt treatment by fasciotomy. Time is a critical factor; the longer the duration of elevated tissue pressure, the greater the potential for disastrous sequelae. Emergency medicine providers must be cognizant of this clinical syndrome so that early emergent surgical consultation can be obtained to avoid complications.
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PMID:Compartment syndrome: a complication of acute extremity trauma. 798 93

The authors present an account of their initial experience with the use of a method of locked nailing of fractures of the leg, applying the technique described by Grosse and Kempf. They use original implants of Howmedica Co. They indicated for osteosynthesis closed fractures of the leg in the middle three fifths of the bone length, without major damage of soft tissues (grade 0 and 1 of Tscherne's classification). In injuries with imminent compartment syndrome they operated after a delay, in all others they operated early after injury. Using the described method, the authors operated 16 patients. In three instances they used static locking of the nail, in 13 instances dynamic locking. The authors did not observe any delayed healing of the fractures. The only complication was partial paresis of the deep branch of the peroneal nerve. In all instances the patients were allowed to weight-bearing of the operated extremity soon--on average 3.5 weeks after operation. Recovery followed after 8-15 weeks. The authors consider this method with regard to the possible functional treatment, stability for weight-bearing, and rapid recovery of the fracture as the optimal therapeutic procedure for almost all types of closed fractures in the middle three fifths of the leg.
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PMID:[Locked nailing of fractures of the long bones. 1. Fractures of the leg]. 834 85

Arthrodesis of the ankle (AA) or the subtalar joint (AST) is still a necessary treatment in case of painful posttraumatic arthrosis or paresis of the muscles after compartment syndrome. Today the alloplastic ankle joint replacement does not satisfy. Many treatments of arthrodesis with minimal or extended resection of the joint surface with or without bone transplantation are described in literature. We present in detail a new developed technique of press-fit dowel arthrodesis (KDA) for the ankle and subtalar joint. After adjustment of the joint position and retention with Kirschner wires the surface of both sides of the joint surface and underlying bone is removed by a cannulated diamond bone cutting device. Dowels from the anterior iliac crest are impacted in the cutted joint defect. The dowels are 1/10 mm bigger in dimension than the primary defect in the joint surface. The surgery will be completed with a compression screw osteosynthesis, at the ankle joint transarticular through the lateral and medial malleolus, at the subtalar joint from plantar. Ten patients have treated by press-fit-KDA (female 2, male 8; AA 7, 33.6 +/- 9 y; AST 3.38 +/- 10.9 y). The indication for KDA was in nine cases a severe posttraumatic arthrosis, in one case the paretic malfunction after compartment syndrome. The arthrodesis were clinically and radiologically consolidated after 8.2 +/- 1.9 weeks. At this time the patients showed no symptoms and were fully mobilised with complete weight-bearing. The advantages of KDA: preservation of the outline of joint and hindfoot, preservation of length of the leg and outline of iliac crest, no risk for the soft tissue, quick consolidation of the arthrodesis, no need of external fixation. The technique is also suitable for other indications as presented.
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PMID:[Press-fit bone dowel arthrodesis of the ankle or the subtalar joint using a diamond bone cutting system. Surgical technique and initial results in 10 patients]. 1098 8

Young patients with gonarthrosis that does not respond adequately to conservative therapy can be treated by corrective osteotomy. Osteoarthritis of one compartment more often has a mechanical aetiology than osteoarthritis of the entire knee. Patients with osteoarthritis of the medial compartment often have a genu varum (bow-legs) while patients with osteoarthritis of the lateral compartment often have a genu valgum (knock-knees). The goal of corrective osteotomy is to transfer the load bearing to the normal compartment, which will reduce the symptoms and permit arthroplasty to be postponed. In retrospective studies, the procedure resulted in less pain, improved knee function or postponement of knee arthroplasty in 28-87% of the patients. Possible complications include pseudarthrosis, thromboembolism, contracture of the patellar tendon, paresis of the N. peroneus, compartment syndrome. The outcome of osteotomy for gonarthrosis depends on careful patient selection, the stage of osteoarthritis, and the achievement and maintenance of the correction of the load axis that was calculated before the operation.
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PMID:[Osteotomy at knee level for young patients with gonarthrosis]. 1563 82

Abdominal compartment syndrome is an increasingly recognized phenomenon. We report the case of an otherwise fit and healthy 42-year-old man who underwent plication of the right hemidiaphragm for idiopathic phrenic paresis. His postoperative recovery was complicated by abdominal compartment syndrome, which was managed conservatively. We believe this is the only report of this complication after diaphragmatic plication and one of very few reported thoracic causes of abdominal compartment syndrome.
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PMID:Abdominal compartment syndrome: a rare complication of plication of the diaphragm. 1679 49


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