Chronic Exertional Compartment Syndrome in Children

Just when you think you have a handle on patient complaints and have a refined working differential diagnosis list for each complaint, a patient comes to teach you something new… and humbles you. Fortunately, I live in a general state of humility. Certainly, it is the humility that keeps us grounded while the healthy arrogance allows us to know we can confront the challenge and make a difference (aka – Humble Arrogance). This past week, one of my esteemed residents, Dr. Rachel Plate, taught me something I had not considered previously. Sure, we are always acutely aware of the threat of Compartment Syndrome after fractures and, of course, we know that children may not present with the “P’s,” but rather the “A’s.” Some of us are wise enough to even know that there does not need to be a fracture to have compartment syndrome develop, but I was not aware of the fact that it can be a CHRONIC condition too! (mind blown) So, thanks to Dr. Plate and her patient, I had to learn something new… and thought I’d share with you a few tasty treats on Chronic Exertional Compartment Syndrome in Children:

Chronic Exertional Compartment Syndrome: Basics

  • First described in 1912 (so… I guess I have no excuse… it isn’t that new)
  • Characterized by: [Buerba, 2019; Tichy, 2019]
    • Reversible increase in compartment pressures
      • Compromised tissue perfusion
      • Pain and Neurologic symptoms
    • Improvement in symptoms with rest (distinctly different from Acute Compartment Syndrome)
  • Known Associations: [Buerba, 2019; Tichy, 2019]
    • More commonly involves the lower extremities than the upper (but can occur in either)
    • Lower extremities often related to:
      • Running sports
      • Marching activities (military)
    • Upper extremities often related to:
      • Rowing
      • Professional motorcyclists
    • Recent studies show increasing numbers in female adolescents.
  • Pathophysiology: [Buerba, 2019; Tichy, 2019]
    • Symptoms are related to the increased compartment pressure adversely affecting blood flow.
      • Patients tend to have increased compartment pressures at rest compared.
      • During exercise the facial compartment does not expand to accommodate the expanding muscle.
    • There is no clear known etiology at this time, but believed to be multifactorial.
    • Likely influential factors:
      • Muscle hypertrophy (those really large calves look cool, but they may be the problem!)
      • Noncompliant fascia
      • Microtrauma
      • Decreased venous return
      • Myopathies
      • Anatomic malalignment or other mechanical stressors
      • Running / exercise technique
      • Improper training technique
  • Management of: [Buerba, 2019]
    • Nonoperative strategies are favored as first line.
      • Cessation of all activities that increase the symptoms.
      • Biomechanical evaluation and changes (ex, gait change)
      • Physical therapy
      • NSAIDs
    • Surgical strategies are used if nonoperative measures fail.
      • Traditional open fasciotomy
      • Endoscopic assisted compartment release
      • Ultrasound-guided fasciotomy
      • Percutaneous fasciotomy
      • Single minimal-incision fasciotomy
  • BONUS MORSEL: Nonfracture Acute Compartment Syndrome [Livingston, 2016]
    • Acute compartment syndrome can occur without presence of fracture.
    • Potential complications similar to acute compartment syndrome associated with fractures.
    • Common etiologies:
      • Trauma (ex, crush injury)
      • Postoperative
      • Infectious
      • Vascular
      • Exercise related (maybe another reason to avoid the marathon)
        • Older adolescent males involved in competitive sports are often seen with this.
        • Have high rates of neurological symptoms on presentation.
        • Diagnostic delay is still common (~48 hrs).

Chronic Exertional Compartment Syndrome: Presentation

  • Diagnosis is often delayed as it can be misinterpreted as other, more common conditions: [Buerba, 2019; Tichy, 2019]
  • History typically consists of: [Buerba, 2019; Tichy, 2019]
    • Pain
      • Localized
      • Dull ache or “fullness”
      • Worsens during exercise (can become sharp, cramping)
      • Usually relieved with rest (within hours of stopping the activity)
    • Neuro complaints (also common)
      • Paresthesias
      • Numbness, and even
      • Transient peripheral nerve palsy (ex, foot drop)
    • Lack of known direct trauma to area
    • Symptoms may occur at “predictable” times of exercise (ex, after reaching certain distance or intensity).
  • Physical exam: [Buerba, 2019; Tichy, 2019]
    • May have objective tenderness, but often not while at rest
    • Do not need to have “tense” compartments on exam.
    • Atrophy of the affected side can actually be seen (if long-standing symptoms)
    • Passive stretching may not cause pain.
    • Exam is often unremarkable (especially if exam is done while at rest).
  • Diagnosis is made by: [Buerba, 2019]
    • History and high index of clinical suspicion
    • Compartment pressures (for Lower Extremities):
      • Pre-exercise pressure >/= 15 mmHg
      • 1-minute post-exercise pressure >/= 30 mmHg
      • 5-minute post-exercise pressure >/= 20 mmHg
      • Any abnormal measurement will suffice (ie, if pre-exercise is elevated, don’t need the others)
    • No consensus on upper extremity pressure measurements, but >/= 30 is abnormal.

Moral or the Morsel

  • Chronic does not mean unimportant. Pay attention to the historic clues and be careful taking a previously given “diagnosis”… it may not be shin splints.
  • Bigger is not always better. That large calf muscle that the teenager soccer player has may be part of the problem… not just a muscle strain.
  • Try not to ignore a symptom just because it doesn’t initially fit with your diagnosis… Paresthesias are usually not associated with shin splints.

References

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. Mallikarjuna Swamy says:

    Informative! Thanks much.

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