Question

Case Study – Lower Extremity Presentation/History At the beginning of the soccer season a 20-year-old college student participated in strenuous filed practice extending through the whole afternoon. Later in the evening he experienced severe pain over the anterolateral aspect of his right leg, radiating down toward the angle. The next afternoon he went back to the field and continued to play, but the pain in his right leg became so severe that he had to limp off the field. The pain persisted throughout the night and the next morning he consulted a physician. Examination On examination there is reddening and swelling over the anterolateral aspect of his right leg. On palpation this area is extremely tender, it feels hard and warmer than other parts of the leg. The hardening extends from two inches below the tibial tuberosity to the junction of the middle and lower thirds of the leg and seems to correspond to the belly of the tibialis anterior muscle. Dorsiflexion of foot and toes is severely limited. The pulses in the anterior tibial and dorsalis pedis arteries are present. His body temperature is slightly elevated. Discussion The condition is caused by an acute impairment of the intramuscular circulation in the muscles of the anterior compartment of the leg. It is assumed that heavy exercise, particularly in an individual who is not conditioned, causes a swelling of the musculature, perhaps also some tearing of muscle fibers and small hemorrhages inside the muscles. This increase in bulk compresses the smaller vessels within the muscle bellies which in turn leads to degeneration and necrosis of muscle fibers. Identify the muscles in the anterior compartment of the leg. The tibialis anterior is particularly affected, and the extensor hallucis longus is affected to a greater extent and more commonly than the extensor digitorum longus and peroneus tertius. 1) Describe the configuration of the anterior compartment that makes this region particularly liable to increase in intra-compartmental pressure (6). In that dorsiflexion of the ankle may be interfered with by anoxia of the muscles within the compartment just as likely as it is interfered with by nerve involvement, a differential diagnosis is necessary. 2) Name the major blood vessel and the major nerve in the compartment that may also be affected by the elevation in pressure (2). 3) Identify the muscle that may be tested in the differential diagnosis of circulatory versus nerve involvement. In your consideration, best to identify the muscle supplied by the deep peroneal nerve that lies outside the compressed compartment, the paralysis of which could be taken as an indication of direct nerve involvement. Note: Its paralysis would prove that the compression involves the deep peroneal nerve within the compartment (1) . Deficiencies in the sensory supply of the skin would also demonstrate that the deep peroneal nerve is directly affected. 4) Identify the area of the skin that would be tested for sensory loss (1). The presence of arterial pulse in the anterior tibial and dorsalis pedis arteries seems to prove patency of the main stem, although, occasionally, a well-established collateral circulation in the distal leg (by means of branches from the arteries in the posterior compartment) may simulate patency in a vessel blocked higher up. The variations in susceptibility of the three main muscles of the anterior compartment to impaired circulation can be explained by differences in the development of the intramuscular arterial anastomoses. Another explanation, frequently offered, is the fact that the anterior tibial muscle has its sole supply from the anterior tibial artery, the less involved extensor hallucis longus receives additional blood from the perforating branch of the peroneal artery, while the extensor digitorum longus obtains its supply from the three major arteries of the leg, including the posterior tibial by way of perforating branches. This latter explanation of the preferential involvement of the anterior tibial muscle presupposes interference with blood flow in the main stem of the anterior tibial artery by elevation of pressure inside the compartment, before its branches enter the musculature. While this occurs, presence of pulsatory excursions in the anterior tibial artery distally and in its continuation, the dorsis pedis artery, as was found in this case, makes such an event improbable.

Answer 1

There are 3 compartments in leg they are

Anterior compartment

Lateral compartment

Posterior compartment

Compartment syndrome of the leg in sports is often due to repetitive strenuous activity and is relieved with rest. The anterior compartment is the most commonly affected

Compartment syndrome is one of a few orthopedic emergencies and is defined as an increase in pressure of the musculofascial sheath such that the compartment pressure exceeds 40 mmHg or is within 30 mmHg of the diastolic pressure . This is usually caused by trauma, and subsequent swelling leads to impaired perfusion of the muscle. If not treated urgently, the ischemia causes destruction of the muscles involved. It is seen most commonly in the anterior compartment of the leg but can affect any area contained within a fascial compartment. Repetitive sporting activity can also lead to this condition over time, and in this case it is termed chronic exertional compartment syndrome.