Eight patients suffered complications such as secondary horseshoe ankle, metatarsophalangeal joint dislocation, foot varus and claw toes, which were too severe to be corrected simply via soft tissue treatment. These eight patients with severe CS complications were the subjects of this study.
Antibiotics were administrated according to drug sensitivity test results to inhibit infection, and drugs were used to maintain normal function of the liver and the kidney. Anti-inflammatory drugs were used to inhibit systemic inflammatory reactions to prevent organ damages. Blood, plasma or albumin transfusion were applied if necessary.
This procedure was performed repeatedly if necessary. After thorough removal of necrotic tissues, wounds were closed via suturing, or in some cases via skin grafting. Within one week after the first wound debridement procedure, all eight patients wore foot drop correction braces Beijing Yian Cubic Medical Tech.
When their ankles could reach the neutral position, the Ilizarov external frames were removed. When the patients practiced walking, their affected feet were further protected by orthopedic insoles to prevent neuropathic ulcers. Correction of foot deformity was carried out by traumatic orthopedic surgeons three months after the wound was stable skin integrity, no ulcers or recurrence of infection. Under spinal or epidural anesthesia, the patient was positioned supine. Then, an assembled and sterilized Ilizarov external frame non-limiting adaptive multidimensional arthrodesis orthotics, Beijing Yian Cubic Medical Tech.
Two Ilizarov rings were placed in proximal and distal ends of the tibia, respectively. These two needles pinned through the tibia and formed an angle of about 50 degrees. Additionally, two Ilizarov rings were connected with four adjustable equally-spaced threaded rods. Then, the Ilizarov ring in the distal end of the leg was connected to the ring surrounding the affected feet with adjustable thread rods.
On the third day after surgery, patients were instructed to take care of the implanted needles and practice interphalangeal joint dorsiflexion. By moving the nuts along the rods gradually towards the ends, the ring around the feet could pivot on the ankle and assist progressive ankle dorsiflexion. Then, autogenous cancellous bones were implanted between two truncated bone ends, which were further fortified with an external fixator to press the bone ends together.
Compartment syndrome: Causes, symptoms, and treatment
Claw toe deformity was corrected by proximal interphalangeal PIP joint resection arthroplasty, while claw toe deformity was corrected by flexor hallucis longus tendon lengthening surgery and metatarsophalangeal joint arthroplasty. Neuropathic ulcers were treated with wound dressings and with local flap grafting if necessary. Before admission to our hospital, five of eight patients were injured in car accidents, two by crush injuries, and one by sharp blades.
Two patients had injuries in the right lower limbs and 6 patients had injuries in left lower limbs. Seven patients had bone fractures. All eight patients had damaged nerves, and peroneal nerve was badly severed in one patient. Five patients had impaired superficial and deep peroneal nerves due to secondary CS on their front and outer legs; two patients suffered superficial peroneal, deep and posterior tibial nerve injuries because of the involvement of multiple compartments, and one of them had sciatic nerve injury; four patients who had impaired blood vessels at the time of injury had vascular reconstruction surgeries at local hospitals; six patients had necrotic muscles of just the anterior and lateral compartments, while two other patients had necrosis in all lower leg muscles except for the gastrocnemius.
Immediately after admission to our hospital, all patients had wound debridement 2—4 times to remove necrotic tissues completely. All patients had various complications after discharge from the hospital. In two patients, neuropathic ulcers on the fifth metatarsal were improved following changing wound dressings. The clubfoot was rectified to the neutral position in Ilizarov external frames for all eight patients. When wearing Ilizarov external frames, four patients experienced claw toes, which were corrected by tendon lengthening and arthroplasty.
Among all eight patients, six patients gradually resumed normal weight-bearing walking. The other two patients had severe clubfoot and received osteotomy and ankle fusion for permanent correction, and resumed walking. A year-old male patient with lower limb CS was transferred to our burn unit on the third day post-trauma.
Three days ago, crush injury occurred in his right thigh resulting in femoral shaft fractures, femoral vessels rupture and right sciatic nerve injury.
Next day, he was transferred to another local hospital for fasciotomy to relieve edema of his right leg. He was then transferred to our hospital because of the complication on the third day after fasciotomy. Representative images of one patient. The wound appearance after compartment fasciotomy of right lower limb. The wound was closed through skin suturation of right lower limb. The equinovarus deformity of right lower limb.
The medial appearance after the application of Ilizarov fixator.
X-ray image after the application of Ilizarov fixator. Image after the arthrodesis was performed. The equinovarus deformity was corrected completely medial appearance. The equinovarus deformity was corrected completely lateral appearance. X-ray showed that the equinovarus deformity was corrected completely. After admission, the patient underwent anti-infection and organ protection treatment. When he was stable, wound debridement was performed 4 times to clear all necrotic tissues with the exception of inner and outer sides of his surviving gastrocnemius heads.
Wounds in the inner side of his leg were sutured, while the wound in the outer side was closed with a piece of skin graft Fig. This patient used crutches to practice weight-bearing walking with the assistance of an orthopedic brace to prevent foot drop.
Distal phalanx - Special considerations
One month later, neurological ulcers appeared on his fifth metatarsal base and were improved following changing wound dressings. The brace to prevent foot drop was then removed when the Ilizarov external frame was installed in order to stretch the muscles. However, this procedure induced claw toes on No. Three months later, his ankle went back to neutral position. The patient was hospitalized again for Ilizarov frame adjustment, ankle fusion, lengthening flexor hallucis longus tendon of his first toe, metatarsophalangeal joint arthroplasty, and PIP joint resection of his No.
Six months later, Ilizarov frame was removed, and the patient resumed normal weight-bearing walking with the assistance of an anti-ulcer insole Fig. Acute CS of the lower leg is not widely reported, but its potential complications can develop after fractures, crush injury, or traumatic injury. Long-term devastating complications are known to seriously impede the mobility of the patients and the quality of life.
CS related disabilities and even death were reported if the diagnoses and treatments were seriously delayed [ 11 , 12 ].
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All eight patients in this study suffered severe CS due to different traumatic injuries. They all had bone fractures and nerve injuries of various extents, damaged vascular and necrotic muscles, as well as severe clubfoot on their affected legs. Even after fasciotomy and other surgical treatment at local hospitals, they still experienced severe tissue dysfunctions and foot deformities, which required further wound treatment and multiple surgeries to achieve anatomical and functional recovery. In this study, we combined a series of treatments that covered every course of CS development and achieved satisfactory clinical outcomes in all patients.
The increase of compartment pressure induces CS, eventually leading to ischemic necrosis of muscles and nerves [ 13 , 14 ]. Lower extremity compartment syndrome from prolonged lithotomy position not masked by epidural bupivacaine and fentanyl. Reg Anesth.
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A report of two cases. Did continuous femoral and sciatic nerve block obscure the diagnosis or delay the treatment of acute lower leg compartment syndrome?
Compartment Syndrome: Management and Treatment
A case report. Pain Med. Iatrogenic compartment syndrome, A follow-up of four cases caused by elastic bandage. Clin Neurol Neurosurg. Bilateral gluteal compartment syndrome. Dodd A, Le I. Foot compartment syndrome: Diagnosis and management. J Am Acad Orthop Surg. Lower limb compartment syndrome: Course after delayed fasciotomy. J Trauma.