Calf or forearm gap syndrome

Introduction Calf or forearm gap syndrome is a clinical manifestation of the compartmental septal syndrome. The fascial compartment syndrome is a progressive lesion that occurs in the specific fascial space of the extremities after limb trauma. That is, due to the increase of the contents of the interstitial, the pressure is increased, and the interstitial contents are mainly progressive ischemic necrosis of the muscle and nerve trunk. . The fascial space syndrome can occur when the volume of the fascial space is increased, the pressure is increased, or the volume of the fascial septum is reduced, and the volume of the contents is relatively increased.

Cause

The fascial space syndrome can occur when the volume of the fascial space is increased, the pressure is increased, or the volume of the fascial septum is reduced, so that the volume of the contents is relatively increased. Common reasons are:

1. Squeeze injury of the limb: the limb is subjected to heavy body bruises, crush injuries or heavy objects for a long time. For example, when the earthquake collapses, the building collapses on the limbs, and the comatose patients such as drunkenness and CO poisoning press on their own limbs. Under the trunk or limbs, the compressed tissue is ischemic. After the pressure is removed, the blood is reperfused, so that the injured tissue is mainly muscle tissue hemorrhage, reactive swelling, and the volume of the contents of the spacer is increased, and the pressure is increased.

2. Limb vascular injury: major vascular injury of the limb, the ischemia of the muscles and other tissues supported by the limbs for more than 4 hours, after the repair of the blood vessels to restore the blood flow, the muscles and other tissues are reactively swollen, so that the contents of the gap increase, and the pressure increases. disease. For example, femoral artery or arterial injury, repair of blood vessels after 4h, may occur in the calf compartment syndrome. Limb traumatic bleeding, in the first aid, the tourniquet time is longer, for example 2 ~ 3h, the limb has not been necrotic, after removing the tourniquet, the limb reactive swelling is severe, the lower leg can occur in the lower leg fascia syndrome. Supracondylar fracture of the humerus, compression, stimulation or injury to the brachial artery, resulting in paralysis of the sputum or blood flow, resulting in forearm muscle ischemia, Volkmann contracture, is also a kind of fascial compartment syndrome.

3. Internal bleeding of limb fracture: limb fracture, bleeding into the fascial space, because the intact structure of the fascial space is not damaged, the blood can not overflow and the volume of the contents increases, so that the pressure increases and the disease occurs, which can be seen in the fracture and forearm Fractures, etc.

4. Improper fixing of gypsum or splint: Many literature reports that the external splint or plaster splint is fixed. Because the over-tightening pressure is too large, the fascial gap volume is compressed, damage the tissue and swelling, and the content of the gap is increased. Prompt relaxation of the splint can occur intrinsic. Seen in the forearm or calf fracture.

5. bleeding of the lumbar muscle: due to trauma or hemophilia bleeding, limited by the muscle sheath, bleeding and swelling, increased pressure, hip deformity, can compress the femoral nerve to the quadriceps paralysis.

6. Others: When the lithotomy is performed, the two calves are placed on the bracket, and the calf triceps are pressed for more than 5 hours, which can also cause the intrinsic. Five cases were reported in the Macintosh, and the posterior fascial compartment syndrome occurred after surgery. Forearm and hand infusion exudation can also cause fascial compartment syndrome.

an examination

Related inspection

Motor function check, neurological examination, general radiography

The onset of fascial compartment syndrome is generally rapid, and severe symptoms can be formed in about 24 hours.

1. Symptoms: Pain and activity disorders are the main symptoms. Pain is generally reported after limb injury, but in the early stage of the compartmental space syndrome, the pain is progressive. The limb is not relieved by limb fixation or treatment, and the muscle is aggravated by ischemia until the muscle is completely necrotic. Previously, the pain continued to worsen without alleviating. As the muscle damage is swollen, active activity is impeded.

2. Signs: swelling, tenderness and passive muscle pulling pain are important signs of this disease. Limb swelling is the earliest sign. In the forearm, calf, etc., due to the tough fascia wrap, the swelling is not very serious, but the skin is swollen and obvious, often blisters. Apparent tenderness at the muscle abdomen is an important sign of muscle ischemia in the fascial space. When the muscle is passively pulled at the end of the limb, such as the forearm fascia fascia syndrome, passive stretching of the straight finger causes severe pain in the flexor muscle.

The ends of the limbs that are fed through the arterial trunk of the fascia septum are mostly normal in color, and the microvascular filling time is basically normal, but the pulse is often weakened or unclear. The nerve trunk is very sensitive to the ischemic response. The nerve conduction dysfunction can occur in a short period of ischemia, which is manifested by the loss of sensation at the end of the limb, the weakening of the muscle strength, and the complete loss of nerve conduction function.

If left untreated, the pathology of the compartmental space syndrome continues to develop, and the muscle nerve trunks are successively necrotic. Therefore, the late signs mainly include limb contracture deformity and nerve trunk injury. In the forearm, the flexor muscle contracture is more severe than the extension side, so it is a wrist and flexion deformity. The inner and inner muscles of the ulnar nerve and the median nerve are paralyzed. In the calf, the muscles of the posterior muscle group are rich, and the degree of contracture is far more serious than that of the anterior tibialis anterior muscle group. Therefore, the fixed horseshoe varus deformity is often present. For example, only the deep toe flexor toe flexor, long flexor and other contractures, it is a flexor flexion deformity. Because the shallow triceps of the lower back of the ankle is not contracted, there is no horseshoe deformity. When the foot is drooping, the toes can be straightened, while in the case of dorsiflexion, the flexor toe deformity appears, and the toes cannot be straightened. The posterior tibial nerve travels in the deep space of the posterior tibial. When it is necrotic, the plantar sensation is lost and the intramuscular muscle is paralyzed. Deep sacral nerves in the anterior tibial space, when necrosis, stretched toe and paralysis. The superficial peroneal nerve and the sural nerve travel outside the deep fascia of the calf. Generally, there is no necrosis, and the feeling of the dominant area exists.

3. The predilection site: the fascial space syndrome is best in the upper limbs of the forearm volar and dorsal fascial space; the lower extremity occurs well in the posterior tibiofibular space and the anterior tibiofibular space, followed by the posterior temporal sulcus. The forearm temporal iliac muscle gap and the lateral calf and iliac muscle gap, although located in the forearm and calf, but the gap in the bone wall is only a single bone (tibia or tibia), rather than the interosseous membrane and the two bones, so the gap It also has relative scalability, with less fascial space syndrome occurring in this gap. Intermuscular intermuscular space in the hand is also the site where fascial compartment syndrome can occur. The upper arm area and the iliac crest muscle space occasionally occur.

Because the pressure in the fascial compartment increases, it can cause changes in the above muscles and nerves. If the time is too long, it will cause irreversible damage and even life-threatening. Therefore, early diagnosis and timely treatment are important. However, its diagnosis is often not easy. Although tissue swelling and muscle ischemia can cause pain, when the injured limb has a fracture, it will also cause severe pain, which easily covers the pain of the compartment syndrome. Missed diagnosis. Sometimes or misdiagnosed as arterial injury, nerve damage, tenosynovitis, cellulitis or deep phlebitis. In particular, when the pressure in the tissue rises to a certain extent, although the small artery can be closed, it may not be enough to affect the blood flow of the main artery of the limb. Therefore, the artery at the distal end of the affected limb may still hit the beat. Capillary filling may also exist, causing misunderstanding that limb blood supply is not impeded, regardless of the formation of a compartment syndrome. During the examination, the affected compartment may have obvious swelling, redness and tenderness, and should not be mistaken for cellulitis or embolic phlebitis.

The nerve examination of the limb is very important. It is necessary to examine the skin sensation in detail, especially the area where the affected nerve is suspected. Muscles in the pressure-increased compartment are weak due to ischemia, while passive activity can cause pain. For example, in the anterior tibialis anterior muscle syndrome, passive flexion of the toes can cause severe pain in the abdomen of the tibialis anterior and extensor muscles. This so-called "passive traction test" has a great impact on early diagnosis of compartment syndrome. help.

According to the results of clinical observations, the examinations after the pressure rise in each fascial compartment are as follows:

Forearm spacer

(1) When it occurs on the dorsal side, the local tissue is tense, there is tenderness, the thumb and the extension of the finger muscles are weak, and the pain is caused when the thumb and fingers are passively flexed.

(2) When it occurs on the volar side, the tissue is tense, the forearm has tenderness on the volar side, the thumb and flexor muscles are weak, the passive thumb stretches the pain, and the skin of the ulnar nerve and the median nerve is lost.

2. Each leg of the interval

(1) There are extensor muscles, extensor muscles, and deep peroneal nerves in the anterior compartment. When the pressure in the interval rises, in addition to tissue tension and tenderness on the anterior side of the calf (sometimes redness and swelling), there may be a loss of skin sensation in the deep branch of the radial nerve, weakness in the toe muscle and tibialis anterior muscle, and pain caused by passive flexion.

(2) There are iliac muscles in the lateral compartment and superficial temporal nerves. When the gap is compressed, the foot cannot be everted, and the skin on the back of the foot feels disappeared. Pain caused by varus in the foot, local skin tension and tenderness are manifested in the lateral tibia of the calf, but it is rare in clinical pressure in this gap. When the above signs appear, the common peroneal nerve injury should be considered first.

(3) There are soleus muscles and gastrocnemius muscles in the posterior compartment of the calf. This gap is more common in the femoral artery and vein injury and only repairs the artery. The signs are manifestations of tonic clubfoot deformity, which causes pain in the muscles when the dorsiflexion is performed, and swelling and tenderness behind the calf.

(4) There are flexor digitorum, posterior muscle, posterior muscle, and posterior tibial nerve in the middle compartment. When the gap is compressed, the flexor digitorum and the posterior tibial muscle are weak, causing pain when the toe is extended. Skin sensation loss after posterior tibial nerve distribution. On the inside of the distal end of the calf, the tissue between the Achilles tendon and the tibia is tense and tender.

Patients with fascial compartment syndrome may have elevated body temperature, increased white blood cell count, and increased erythrocyte sedimentation rate, but this does not necessarily indicate that the patient has an infection. Fascia septal syndrome is a developmental disorder. It may not be obvious when it occurs. If you encounter suspicious conditions, you should observe it closely and check it for early diagnosis and timely treatment.

Differential diagnosis

Differential diagnosis of calf or forearm gap syndrome:

1, limb weakness: limb weakness refers to the appearance of normal limbs, the limbs are soft and weak. Often with sleepiness, dizziness and other symptoms. Chinese medicine believes that it is a yang deficiency, and it cannot be caused by nutrition and excitement. After the pathological disease is excluded, it is mostly sub-healthy.

2, limb movement uncoordinated: in the absence of muscle strength, the coordinated movement of limb movements, imbalance and incoordination, known as ataxia. Ataxia telangiectasia is a neurocutaneous syndrome characterized by progressive cerebellar ataxia, ocular telangiectasia, and repeated upper respiratory tract infections. Girls have more morbidity than boys. The most obvious change in this disease is vasodilation of the bulbar conjunctiva, followed by telangiectasia of the eyelid skin, followed by telangiectasia of the face, ear and neck. Sometimes the skin can also be seen with changes in coffee milk spots, pigmentation spots, and the like. The neurological symptoms first manifested as cerebellar ataxia, which began to manifest when walking, 18 to 24 months after birth began to appear symptoms, but also started to become sick after 5 years of age, sick children appear inconsistent movement, walking gait Stable, inaccurate with the finger nose, etc., to 12 to 15 years old to develop completely unable to walk. As the disease progresses, the intelligence gradually diminishes. Children with this disease often have a history of repeated upper respiratory tract infections, or recurrent pneumonia and sinusitis. Blood immunoglobulin (lgA) was reduced.

3, limbs are sore and weak: hands, legs, knees and limbs are sore and weak, the actual category of Chinese medicine is called snoring, is an important signal that the wind, cold, wet, evil gas invades the body, when the evil gas invades the internal organs, the first Feelings are sore hands and feet, soreness, sinking, pain, and acupuncture. This is the signal that the meridian is blocked. It is also the last line of defense for the human body. If it is not treated in time, the meridian is damaged, thus destroying the nerve conduction of the human body. Functional system, causing nerve necrosis, and finally stroke, hemiplegia, myocardial infarction, cerebral infarction, diabetes gangrene, regret for life.

4, joint pain: in life, many people suffer from joint pain. There are many causes of joint pain. According to age, gender, site of onset, and symptom characteristics, soft tissue, cartilage, bone and inflammation can be summarized. Arthritis caused by any cause, such as timely medical treatment, symptomatic treatment, can generally cure or alleviate.

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