Chronic Compartmental syndrome

Chronic Compartmental syndrome is a pretibial pain induced by exercise seen in the anterior compartment of the leg in athlete's. If the compartmental pressure is more than 15 mm Hg at rest, more than 30 mm Hg diring exercise and more than 20 mm Hg for 5 minutes after exercise, chronic Compartmental syndrome is suspected. Due to the herniation of fat or muscle through the fascial defect, a soft tissue mass is seen in the anterolateral aspect of the lower third of the leg. The patient is instructed to alter or decrease the level of activity, if no relief is forthcoming surgical decompression is indicated.


Nonunion
The difference between delayed union and nonunion is of degree. In delayed union, healing has not advanced at the average rate for location and type of fractures, but healing can still take place if the limb is immobilized for a longer period. In nonunion, there is evidence to show clinically and radiologically that healing  has ceased and union is improbable and needs surgery. Final status of nonunion is pseudarthrosis.


Definition (FDA panel)
Nonunion is said to be established when a minimum of 9 months has elapsed, since the injury and the fracture shows no radiologically visible progressive signs of healing continuously for 3 months.

Causes
Nonunion of fracture is a very notorious complications to treat. Infected nonunion challenges the clinical acumen of best of orthosurgeons. There are various causes leading to nonunion and the following are some of those.

Compound fractures
There are extensive damage to the soft tissue in open fracture and there could be even loss of small pieces of bone. The former results in impaired blood supply to the fracture  fragments jeopardizing the chances of union.

Infection
This is commonly seen in compound fractures and in post surgical infections. Hence, infections should be kept at a minimum in treatment of fractures.

Segmental fractures
In this tupes of fractures, there is a maximum risk of damage to the intraosseous vessels resulting in poor union.

Distraction of fracture fragments
This happens when excessive weight is used during skin or skeletal traction.

Soft tissue interposition
If soft tissue such as periosteum, muscles, tendons, nerves, vessels,  etc.  Are interposed between the fracture fragments it obstructs the growth of internal callus and thus jeopardize union.

III-advised open reduction
Open reduction damage favorable factors for fracture union like fracture hematoma.  Periosteal stripping and these are detrimental to fracture healing.

Insecure and inadequate fixation
Insecure and inadequate fixation of fracture fragments by plate and screws or intramedullary fixation allows micro movements, which prevent union. Apart from these local factors, the general factors, which contribute  to poor healing of fracture are anemia, general debility, cachexia,steroid therapy, osteoporosis, malignancy, etc. But it can be observed that most of the factors, general or local, responsible for poor fracture healing are preventable, if one exercise utmost caution and care during the treatment of fractures.

Clinical features
Clinical features can be discussed under three healings.

History
Usually patients give history  of trauma resulting in fractures,  multiple injuires, multisystem or head injuries. There could be history of open fractures, delay or improper, or inadequate treatment.  It should be noted that, in nonunion the history is of a longer duration.

Symptoms
The acute symptoms seen in fresh fractures are conspicuously absent in nonunion.  There is usually history of no pain or minimal pain. There could be presence  of a deformity or loss of function.

Signs
The important clinical signs are painless abnormal mobility, no crepitusx shortening, scars and sinuses, deformity, wasting  of limb muscles, etc.

Investigations

Radiograph
Plan x-ray helps to identify the types of nonunion, weather it is atrophic or hypertrophic.

Management

Principles

  • Nonunion is an absolute indication for surgery and it requires open reduction, rigid internal fixation and bone grafting.
  • There is no role of conservative treatment 
  • Other methods of treatment include electrical stimulation, interlocking nails and ilizarov.
Role of ilizarov in nonunion 
This alows simultaneous corrections of all deformities and bone loss. In hypertrophic nonunion corticotomy, bone transport and compression helps. Corticotomy provides some of the same biological benefits as bone graft.  Segmental nonunion is also successful.  Ilizarov provides dramatic results,  but is technically very demanding.  It is still the best way to treat cases of infected nonunion. 

Role of physiotherapy in nonunion 
  • Active exercises to the unaffected joints
  • Isometric to the immobilized joints
  • Active ankle exercises to prevent DVT
  • After fracture union is achieved, the rehabilitation is the smae as for other fractures.

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