Chronic exertional compartment syndrome of the forearm in motocross racers: findings on MRI

Predictors of Acute Compartment Syndrome in Patients With Forearm Fractures: A Systematic Review

Acute compartment syndrome (ACS) is a critical orthopedic and traumatology emergency arising from elevated pressure within a confined osteofascial compartment, leading to compromised blood circulation and tissue ischemia. This systematic review aims to comprehensively identify and analyze the most predictable risk factors associated with ACS development in patients with forearm fractures. Published articles on ACS were meticulously searched and evaluated on reputable medical databases such as PubMed. The keywords "risk factors associated with the ACS in patients who have sustained forearm fractures"were used to create the search syntax on various databases. Data were gathered on raw prevalence, population under study, and methodology. A total of 10 articles that met the search criteria were identified and included in this review with a total of more than 300,000 patients across the studies. Fracture-related ACS was the most common, followed by soft tissue damage among patients with forearm fractures. This review underscores fractures as primary ACS catalysts, along with the role of soft tissue trauma. Meticulous consideration of these risk factors can enhance clinical decision-making, early detection, and intervention, improving patient outcomes and care quality.

The Perils of Riding Motocross: A Summary of this Extensive, Prospective Study

Background

Motocross is a high-risk form of motorbiking where serious injuries occur regularly, although little data have been collected to illustrate this relationship. Over 5 years, teams from RJAH Oswestry and RSH sought to demonstrate the impact of Motocross on orthopaedic presentation and workload.

Method

Data were collected prospectively over 5 years including 615 orthopaedic injuries associated with both recreational and competitive motocross.

Results

An increase in injury and operation frequency was observed, young males were identified as the highest risk participant. This was evident over winter and weekends, during the competitive racing season. A variety of injuries have been implicated, some with life threatening or disabling consequences.

Conclusion

Motocross has seen exponential growth in popularity with increases in injuries and operations. This implicates major impacts on finances and healthcare, especially at times of seasonal vulnerability. The authors encourage event organisers to explore the avenues of rider safety in this increasingly popular sport.

MRI findings in chronic exertional compartment syndrome of the forearm: Using signal intensity ratio as a diagnostic tool

BACKGROUND

Chronic exertional compartment syndrome (CECS) of the forearm is a rare but important cause of morbidity amongst athletes involved in strenuous upper limb activities. The diagnosis remains challenging due to the absence of objective, reproducible diagnostic studies.

OBJECTIVES

To assess and quantify signal intensity (SI) changes of involved muscles in patients with CECS of the forearm compared to healthy control subjects competing in similar sporting disciplines. Also, to objectively measure MRI SIs within muscle compartments when using a pre- and post-exercise regime and calculating a signal intensity ratio (SIR) between post- and pre-exercise studies.

METHOD

The study retrospectively examined MRI scans of patients treated for CECS of the forearm and compared these to the MRI scans of asymptomatic high-level rowers. A specific, reproducible pre- and post-exercise MRI scanning protocol was utilised in both patient and control subjects between 2011 and 2020. Signal intensities were evaluated pre- and post-exercise in involved muscle groups and ratios were calculated.

RESULTS

A total of 86 SIs were measured (43 pre- and 43 post-exercise) in nine study participants (five patients and four controls). After post:pre-exercise comparisons, a statistically significant difference was found between control and patient groups (p = 0.0010). The extensor carpi radialis, flexor digitorum profundus and flexor digitorum superficialis muscles were most commonly involved.

CONCLUSION

This study confirms that significant SI changes are apparent in patients with CECS of the forearm when making use of a standardised pre- and post-exercise MRI protocol. Furthermore, SIR may be used to accurately diagnose CECS of the forearm.

Lacertus syndrome: Use of pre- and post-exercise MRI to aid in diagnosis and treatment

Lacertus syndrome is a chronic exertional compartment syndrome of the forearm that is unlike exertional compartment syndrome of the lower extremity. It differs from traditional exertional compartment syndrome in terms of the anatomy, symptoms and physical exam findings. This is a case where dynamic magnetic resonance imaging is used to confirm the diagnosis rather than relying solely on a clinical diagnosis or invasive compartment pressure monitoring. Surgical release of the lacertus fibrosis can effectively relieve the pressure over the pronator and allow the patient to resume previous activities.

Chronic exertional compartment syndrome of the forearm: a systematic review

The aim of this systematic review is to understand which surgical procedure provides better results in terms of pain relief and function in the treatment of chronic exertional compartment syndrome (CECS) of the forearm.

We searched Medline (PubMed), Web of Science, Embase and Scopus databases on 8 July 2020. Twelve studies were included in this review.

We assessed the quality of the studies using the Coleman Methodological Score.

Data on demographic features, operative readings, diagnostic methods, follow-up periods, type and rates of complications, survivorship of the procedure, return to sport activity, and outcome measures were recorded.

In conclusion, compared to the other techniques, endoscopic fasciotomy delivers similar success rates and lower incidence of complications.

Cite this article: EFORT Open Rev 2021;6:101-106. DOI: 10.1302/2058-5241.6.200107

Mini-Open Surgical Fasciotomy for Chronic Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Adolescents

OBJECTIVE

Evaluate treatment and outcome of mini-open fasciotomy (MOF) in a population of adolescent motorcycling racers affected by forearm chronic exertional compartment syndrome (CECS).

DESIGN

Prospective case series.

SETTING

University hospital/private practice.

PATIENTS

Nine professional motorcycling adolescents were diagnosed with forearm CECS. All were treated with MOF between 2007 and 2012 and followed for a minimum of 5 years (range 5-10 years). Age, sex, body mass index, laterality, and profession were recorded.

INTERVENTIONS

A MOF to obtain decompression of all compartments was performed in all patients.

MAIN OUTCOME MEASURES

Visual analog scale; a subjective scale to measure strength; and Quick-DASH functional scores. Time to resume full riding capacities as the short-term evaluation.

RESULTS

A significant decrease in visual analog scale (P < 0.001) and Quick-DASH (P < 0.001) scores was observed in the first 3 months, stabilizing during follow-up (P = 0.521; P = 0.217). Average time to return to sport was 2.8 ± 1 week. No symptom recurrence was reported, but one patient suffered a minor complication. There were no cases of infection, hematoma, or peripheral nerve injury.

CONCLUSIONS

We assess that MOF can be a valid alternative for the treatment of forearm CECS in adolescent competitive motorcycling racers, as demonstrated by the good success rate and minimal incidence of complications during follow-up.

LEVEL OF EVIDENCE

IV, case series.

Post-Exertional MRI Is Useful as a Tool for Diagnosis and Treatment Evaluation for Chronic Exertional Compartment Syndrome of Forearms

Background: Chronic exertional compartment syndrome (CECS) is a rare condition, which generally occurs in athletes. Few tools are available for diagnosis and treatment evaluation. We examined pre- and post- exertional forearm magnetic resonance imaging (MRI) before and after fasciotomy since 2013. The purpose of this study was to evaluate the efficacy of pre- and post-exertional MRI before and after fasciotomy. Methods: We treated 8 forearms of 5 patients diagnosed with CECS of the forearms since 2013, including 6 forearms of 3 motocross racers, 1 forearm of 1 baseball pitcher, 1 forearm of 1 manual laborer with a history of muscle contusion. We obtained pre- and post-exertional MRI before and after fasciotomy in all cases. Pre-exertional MRI was obtained when the patient was at rest without any symptom. Post-exertional MRI was obtained after the patients repeated "grip and release" using a hand gripper with maximum effort for approximately 10 minutes until symptoms occurred. We compared MRI findings before and after fasciotomy and evaluated the correlation with clinical outcome. Results: Symptoms disappeared completely in all 3 motocross racers after fasciotomy. MRI at rest showed no abnormal high signals in all cases both before and after fasciotomy. On post-exertional MRI, T2 high area presented mainly in flexor digitorum profundus (FDP) and brachioradialis (BR) and disappeared completely after surgery. Symptoms persisted in the pitcher and the laborer after fasciotomy. T2 high area presented mainly in FDP on post-exertional MRI before fasciotomy and remained on post-exertional MRI after fasciotomy in these two patients. These intensity changes correlated strongly with their symptoms. Conclusions: We performed pre- and post-exertional MRI before and after fasciotomy. The intensity change in T2-weighted images on post-exertional MRI correlated strongly with their symptoms. Post-exertional MRI is useful for diagnosis and treatment evaluation in CECS.

Long-Term Outcome of Mini-Open Surgical Decompression for Chronic Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Riders

OBJECTIVE

To evaluate results of mini-open fasciotomy (MOF) in high-level motorcycling or motocross riders with chronic exertional compartment syndrome (CECS) at long-term follow-up (minimum 5 years).

DESIGN

Case series.

LEVEL OF EVIDENCE

IV.

SETTING

University Hospital/Private Practice.

PATIENTS

Fifty-four professional motorcycling riders treated with MOF for a CECS of the forearm from January 2006 to June 2011. Inclusion criteria comprised: high-level motorcycling or motocross riders, clinical symptoms of CECS for at least 6 months, diagnosis confirmed using preoperative compartment hydrostatic pressure measurement and/or magnetic resonance imaging of the forearm, minimum follow-up of 5 years.

INTERVENTIONS

A MOF to obtain decompression of all compartments was performed in all patients.

MAIN OUTCOME MEASURES

Visual analog scale; a subjective scale to measure strength; QuickDash functional scores. Time to resume full riding capacities as short-term evaluation.

RESULTS

A total of 54 patients who underwent 77 MOF procedures overall (23 bilateral) were included. The mean age was 23.6 ± 5.2 years. Mean Visual Analog Scale decreased from a preoperative value of 68.2 to a 3-month postoperative value of 26 (P < 0.001). Mean QuickDash scale was 84 at preoperative registration, falling to 20, 3 months after surgery (P < 0.001) and down to 12 at 1-year follow-up (P = 0.017). The average time to return to full riding capacities was 3.5 ± 1 week.

CONCLUSIONS

Mini-open fasciotomy resulted safe and effective for the treatment of chronic exertional compartment syndrome in high-level motorcycling or motocross riders. The good outcome at follow-up resulted stable at 5 years and the incidence of complications remained low. Our data demonstrate that the resolution of symptoms is reliable and durable. Pain recovery was immediate after surgery, instead functional scores showed a more gradual recovery throughout the 12 months after surgery.

CLINICAL RELEVANCE

Mini-open fasciotomy is a reliable treatment for CECS of the forearm in professional motorcycling riders. This treatment should also be considered in young riders due to the absence of tardive relapse reported in this study.

Hand and Wrist Injuries Related to Motocross Injuries: 5 Year Series

Background: The increasingly fashionable sport of motocross is practiced worldwide by millions of people, but there is very little in the literature regarding its associated injuries and their prevention. We therefore present the first comprehensive, prospective study looking at hand and wrist injuries resulting from motocross injuries in the UK.

Methods: Data was prospectively collected over a 5-year period (from 2010 to 2015) at our regional trauma unit. We exclusively looked at motocross riders. Injuries sustained via motorcycle were excluded from our study.

Results: During the period studied (five years), 615 injuries were collected, including 240 patients with 265 hand and wrist injuries. Most of injuries were sustained in male patients. The patient’s age range was from 4–78 years with most injuries occurring during the spring and summer months. A total of 96 (40%) patients required operative treatment. The most common injury pattern was distal radius fractures (n = 53, 20%), followed by metacarpal fractures (n = 38, 14%) and phalangeal fractures (n = 36, 13.5%).

Conclusions: This study shows the impact and incidence of related hand and wrist injuries. Motocross is a globally fashionable sport. This study shows that the number of annual tournaments and racers have doubled in last 5 years. The number of hand and wrist related injuries and operative requirements have quadruples over the last five years. It is recognized as a high-risk sport despite the use of protective equipment and course adaptions. These injuries can have implications for nearby treating hospitals.

Chronic exertional compartment syndrome of the forearm

Chronic exertional compartment syndrome (CECS) is an overuse injury characterized by increased intracompartmental pressure during exercise. CECS has been described in the foot, thigh, and trunk, but 95% of cases occur in the lower leg. Interestingly, CECS may also affect the upper extremities and has been best described in the forearms. Unfortunately, due to the rarity of this condition, there is no consensus regarding its diagnosis and treatment. This review seeks to discuss the prevalence, etiology, diagnosis, and treatment of CECS of the forearms, which has been described in the literature.

Magnetic resonance imaging in exertional compartment syndrome of the forearm: Case-based pictorial review and approach to management

Exercise-related limb pain poses a management dilemma to the clinician. The term ‘chronic exertional compartment syndrome’ (CECS) (previously known as ‘anterior tibial syndrome’) refers to a condition characterised by exercise-induced pain in one or more muscle groups and is more commonly seen in the lower limbs. Much less has been reported about the upper limbs where the muscular compartments are variably noted to be involved. A high index of clinical suspicion should therefore be maintained to avoid missing the diagnosis. Although commonly noted in athletes, CECS can occur in any age group with any level of exercise activity. In addition, there is no age predilection and the syndrome may be bilateral. The exact prevalence is not known as many athletes modify their training methods, thus delaying or avoiding medical assistance and imaging. The pathophysiology of compartment syndrome is complex. In this review of the syndrome, we describe the cycle of intracellular events leading to CECS and the eventual destruction of muscle. There is considerable overlap with the many possible causes of limb pain. Even the most experienced clinicians experience some difficulty in making this diagnosis of CECS, but with increasing awareness of this entity and availability of good-quality magnetic resonance imaging to confirm the suspicion, upper limb CECS is being more commonly diagnosed and patients more timeously managed.

Chronic Exertional Compartment Syndrome in the Forearm of a Collegiate Softball Pitcher

BACKGROUND

Chronic exertional compartment syndrome (CECS) is a recognized condition in the lower limb, with many reports in the literature. However, very few instances include CECS of the upper limb. This article presents the case of a collegiate softball pitcher presenting with CECS in her right forearm. To our knowledge, this is the first case report of a softball player with CECS, with only one similar incident in a major league baseball player.

PURPOSE

The rarity of this condition normally places it low on the differential diagnosis. However, we hope that the presentation of this case and the review of the literature will aid in making swift and accurate diagnoses of CECS in future patients. We discuss the importance of three specific modalities in the diagnosis of this patient, what diagnostic criteria proved less conclusive, and the paradoxical course the syndrome presented with.

STUDY DESIGN

Case Review RESULTS: Over a six-month period, the patient presented with peculiar presentations and exam results. A broad list of differential diagnoses had to be narrowed down through the presence or absence of relevant findings. These included cessation of exercise for 1 month, physical therapy, anti-inflammatory medicines, an electromyography/electromyogram (EMG), nerve conduction study (NCS), non-exercise magnetic resonance imaging (MRI) of the forearm, cervical MRI, and cervical computed tomography (CT) angiogram. After the above interventions were attempted and the relative findings of three important modalities were summarized, a fasciotomy and release of the dorsal, volar, and mobile wad compartments was performed. The patient's symptoms were relieved, and she eventually returned to full play in softball at the university.

CONCLUSIONS

The three diagnostic criteria we believed to be most helpful in this case, and for future cases of CECS in the forearm, include the clinical presentation, pre- and post-exercise MRI, and pre- and post-exercise compartment pressure measurements.

CLINICAL RELEVANCE

Chronic exertional compartment syndrome of the forearm is extremely rare, especially in the female athlete. This case report and review of the literature may be helpful to the clinician facing similar cases. It describes which clinical tests are most helpful for diagnosis and which findings may be distracting.

Chronic Exertional Compartment Syndrome in Athletes

Chronic exertional compartment syndrome (CECS) refers to exercise-induced, reversible increases in pressure within well-defined inelastic fascial compartments leading to compromised tissue perfusion followed by functional loss, ischemic pain, and neurologic symptoms. Symptoms typically resolve when the activity ceases and there are usually no permanent sequelae. In the upper extremity, this condition most commonly affects athletes during sports requiring repetitive and vigorous gripping, such as rowers. In addition to clinical history and examination, a number of methods aid diagnosis, including compartment pressure measurements, magnetic resonance imaging, and near infrared spectroscopy. When symptoms persist despite conservative treatment, multiple operative techniques have been described to treat CECS including open, mini-open, and endoscopic release of involved compartments. We review the pathophysiology, diagnostic modalities, treatment strategies, and outcomes data for CECS of the upper extremity while highlighting areas of residual controversy.

Motocross biking for competition and for recreation: a prospective analysis of 423 injured riders

Background

Motocross is a form of motorcycle racing held on established off-road circuits and has been a recreational and competitive sport across the world for over 100 years. In the UK alone, motocross has grown into a phenomenally ambitious and popular franchise. There are over 200 motocross clubs across the country, permitting over 900 events annually.

Method

Data were collected prospectively over 4 years (from 2010 to 2014) at our unit. All injuries caused by motocross biking that were referred to our trauma and orthopaedic department were included in this study, regardless of whether the rider was performing the sport competitively or recreationally.

Results

During the period studied (4 years), 423 patients were included with a total of 485 injuries, ranging from 1 to 6 injuries per patient. The patient's age range was from 4 to 73 years, with most of the injuries being sustained within the early spring and summer months representing the start of the motocross season.

Conclusions

We present the first epidemiological study of motocross injuries in the UK. Within the growing culture of ‘adrenaline sports’, motocross has become an exhilarating and extremely fashionable pastime. This study has identified and categorised the spectrum of injuries from upper limb fracture dislocations to life-threatening head and chest injuries, some of which are serious and may cause significant morbidity and possible mortality. These injuries could have significant resource implications, especially for smaller rural hospitals.

Endoscopic decompression for chronic compartment syndrome of the forearm in motocross racers

PURPOSE

Sporting activities that involve repetitive stress to muscle compartments can elicit chronic exertional compartment syndrome. Its occurrence in the lower leg muscle compartments is most common, but other locations are less well known and the pathophysiology is not completely understood. In motocross racers, chronic exertional compartment syndrome can occur in the muscles of the lower arm. Currently, the only accepted treatment of correctly diagnosed chronic exertional compartment syndrome is surgical release of the fascia, which successfully relieves pain and allows patients to return to full activity. Open decompression is considered as the gold standard of treatment. This clinical paper describes our new endoscopic technique and investigates the functional outcome after surgery.

METHODS

We report on a series of 154 chronic exertional compartment syndromes afflicted motocross racers treated with an endoscopic release of the lower arm muscles. An MRI scan before and after strenuous exercise of the hand flexors (repetitive grip until exhaustion for 15 min) was performed to confirm the clinical diagnosis of chronic exertional compartment syndrome. Symptom severity before and after surgery was assessed using a visual analogue scale.

RESULTS

Preoperative symptom severity scores were 1.1 ± 0.3 before exercise and 7.4 ± 1.5 after exercise. Post-operatively, these were 1.0 ± 0.2 and 1.7 ± 0.9. The pre- versus post-operative symptom scores after exercise were significantly different (p < 0.0001). No perioperative complications occurred, and at 6 weeks, all of the racers resumed their sportive activities.

CONCLUSION

It can be concluded that endoscopic release of the superficial compartment of the forearms of motocross racers diagnosed with chronic exertional compartment syndrome is a valuable treatment option, with mild post-operative pain and fast recovery.

Normative MRI, ultrasound and muscle functional MRI findings in the forearms of asymptomatic elite rowers

OBJECTIVES

Forearm injuries are common and debilitating to elite rowers. Chronic exertional compartment syndrome, intersection syndrome and proximal radial bone stress injuries have been documented in this population. This paper explores the imaging findings related to these conditions in asymptomatic elite rowers.

DESIGN

Observational study.

METHODS

19 asymptomatic senior elite and under-23 rowers currently competing at National level or above underwent ultrasound (US), Magnetic Resonance Imaging (MRI) and muscle functional MRI evaluation of their forearms. A comprehensive evaluation sheet identifying characteristics of bone stress, intersection syndrome and chronic exertional compartment syndrome was utilised based on a literature search and review by senior clinicians working with this population.

RESULTS

Peritendinous fluid of Extensor Carpi Radialis Longus (n=10, 53%) or Extensor Carpi Radialis Brevis (n=6, 32%) was a common finding on US. MRI had a higher rate of identification than US. Extensor Digitorum (Coeff=-1.76, 95%CI -3.04 to -0.49), Flexor Carpi Radialis (Coeff=-2.86, 95%CI -5.35 to -0.38) and Flexor Carpi Ulnaris (Coeff=-3.31, 95%CI -5.30 to -1.32), Pronator Teres (Coeff=-3.94, 95%CI -6.89 to -0.99), and Supinator (Coeff=-168, 95%CI -3.28 to -0.02) showed statistically significant changes immediately post-exercise. Mild proximal radial marrow hyperintensity was present (n=15, 78.9%) with three participants (15.8%) also having mild periosteal oedema of the radius.

CONCLUSIONS

Imaging findings commonly seen in symptomatic populations are observed in elite, asymptomatic rowers. Care should be taken when diagnosing bone stress injuries, intersection syndrome and compartment syndrome on imaging findings alone. Data presented can be utilised as a normative dataset for future case studies.

Necrotizing fasciitis and its mimics: what radiologists need to know

OBJECTIVE

The purpose of this article is to review the imaging features of necrotizing fasciitis and its potential mimics. Key imaging features are emphasized to enable accurate and efficient interpretation of variables that are essential in appropriate management.

CONCLUSION

Necrotizing fasciitis is a medical emergency with potential lethal outcome. Dissecting gas along fascial planes in the absence of penetrating trauma (including iatrogenic) is essentially pathognomonic. However, the lack of soft-tissue emphysema does not exclude the diagnosis. Mimics of necrotizing fasciitis include nonnecrotizing fasciitis (eosinophilic, paraneoplastic, inflammatory (lupus myofasciitis, Churg-Strauss, nodular, or proliferative), myositis, neoplasm, myonecrosis, inflammatory myopathy, and compartment syndrome. Necrotizing fasciitis is a clinical diagnosis, and imaging can reveal nonspecific or negative findings (particularly during the early course of disease). One should be familiar with salient clinical and imaging findings of necrotizing fasciitis to facilitate a more rapid and accurate diagnosis and be aware that its diagnosis necessitates immediate discussion with the referring physician.

Chronic exertional compartment syndrome of the forearm in an elite rower

We report a case of chronic exertional compartment syndrome (CECS) affecting the volar forearm compartment of an elite rower. CECS of the forearm is a less well recognised entity than lower limb CECS. We describe a typical history and detail a potential treatment.

Compartment syndrome of the upper extremity

Compartment syndrome involves the sustained elevation of interstitial tissue pressures within an osteofascial envelope to nonphysiologic levels. Tissue injury involves a spectrum from reversible to irreversible damage and, therefore, early recognition and treatment is critical for optimal outcomes. This article reviews the nature of upper extremity compartment syndrome; considers the general classification scheme and potential causes; and discusses the pertinent anatomy, pathophysiology, treatment recommendations, and outcomes for this challenging condition.