Chronic exertional compartment syndrome of the forearm: a case series of 12 patients treated with fasciotomy

Diagnostic criteria of forearm Chronic Exertional Compartment Syndrome: A systematic review

BACKGROUND

Chronic Exertional Compartment Syndrome (CECS) of the forearm is characterized by an increase of the pressure in the forearm compartments during repeated activities. Its diagnosis is challenging because of the lack of clearly established diagnostic criteria.

PURPOSE

We aimed to provide a comprehensive description of the diagnostic methods used for CECS of the forearm, to assess if a more effective diagnosis strategy could be identified.

METHODS

We used PubMed, Google Scholar, Cochrane Library and Science Direct databases to search articles. We carried out multiple searches using the mesh terms ("Chronic Exertional Compartment Syndrome" OR "Chronic compartment syndrome" OR "Exertional compartment") AND ("forearm" OR "upper limb"). Inclusion criteria were prospective or retrospective studies on CECS of the forearm including case reports. We used PRISMA guidelines. The included studies were critically appraised using GRADE approach.

RESULTS

A total of 625 articles were screened and 33 studies were included. It represented 590 patients (505 men and 85 women), with a mean age of 26.6 years old. Among them, 282 competed at an elite level. Motorcycling and motocross were the most frequent sports (66%). Six diagnostic methods were employed. Intra-compartmental pressure (ICP) measurement was the most frequently used method in 26 studies. Magnetic resonance imaging was performed in 9 studies, while electromyography was employed in only 2 studies. One study reported the measurement of grip strength using a manual dynamometer, one study compared forearm circumference before and after effort, and one used myotonometry. Various exercise protocols were observed. Stress-testing using a hand-grip was the most common protocol in 14 studies. Exercise duration varied from 2 min to 60 min.

CONCLUSION

Existing data do not provide sufficient evidence to favor an alternative diagnostic method over ICP measurements that should be used cautiously given the absence of formal validation. Non-invasive methods might be easier to use, but should be subjected to further research.

LEVEL OF EVIDENCE

III.

Return to Sport After Fasciotomy for Chronic Exertional Compartment Syndrome of the Forearm: A Systematic Review

BACKGROUND

Forearm chronic exertional compartment syndrome (CECS) can represent considerable functional impairment in certain active populations, particularly motorcycle racers. Patients with forearm CECS frequently require fasciotomy to relieve symptoms and return to sport (RTS).

PURPOSE

To evaluate the rate at which athletes RTS after fasciotomy for forearm CECS and to compare RTS outcomes between fasciotomy techniques.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the PubMed, Scopus, and Cochrane databases was performed from database inception to December 2022 to identify all published reports of forearm CECS managed with fasciotomy. Included studies were analyzed for demographic information, surgical approaches, rehabilitation parameters, RTS rates, time from surgery at which athletes resumed sport, complications, and recurrence.

RESULTS

A total of 38 studies (15 level 4 case series, 23 case reports) accounting for 500 patients (831 forearms) who underwent open fasciotomy (112 patients), minimally invasive fasciotomy (166 patients), and endoscopically assisted fasciotomy (222 patients) satisfied inclusion criteria. Most patients (88.0%) were motorcycle racers. The overall RTS rate at any level (RTS-A) was 94.2% (97.3%, 92.2%, and 98.5% for the open fasciotomy, minimally invasive fasciotomy, and endoscopically assisted fasciotomy groups, respectively; P = .010), and the overall RTS at preinjury level or higher was 86.8% (95.9%, 85.6%, and 95.2% for the open fasciotomy, minimally invasive fasciotomy, and endoscopically assisted fasciotomy groups, respectively; P = .132). There was a significant difference in RTS-A between the minimally invasive fasciotomy and endoscopically assisted fasciotomy groups (P = .004). The overall RTS time was 5.1 ± 2.3 weeks, patient satisfaction was 85.1%, and the recurrence rate was 2.4%, and there were no significant differences between fasciotomy approach groups (P = .456, P = .886, and P = .487, respectively).

CONCLUSION

Patients who underwent fasciotomy for forearm CECS had high rates of RTS, quick RTS time, high levels of satisfaction, and low rates of recurrence. Outcomes were largely similar between the 3 fasciotomy approaches.

Anconeus Exertional Compartment Syndrome and Posterolateral Rotatory Elbow Instability: A Clinical Association and Rare Cause of Elbow Pain

Background

Anconeus compartment syndrome is a rarely reported compartment syndrome in the anconeus muscle compartment of the forearm. It has anatomic and pathophysiological associations with posterolateral rotatory instability (PLRI) of the elbow.

Purpose

To present the history, management, and outcomes of 4 patients with anconeus compartment syndrome. Secondary aims were to (1) establish normative anconeus pressures and (2) measure the volume of this compartment with and without PLRI in cadavers.

Study Design

Case series; Level of evidence, 4.

Methods

Four patients with clinical signs of anconeus compartment syndrome (2 gymnasts, 1 swimmer, and 1 footballer/weightlifter) were identified over a 3-year period (2015-2017 inclusive). Patient history, sporting activity, physical examination, anconeus compartment pressures, and treatment outcomes were recorded. Manometry of the anconeus compartment in 2 healthy male controls was performed to establish normative compartment pressures. Anconeus volumetric anatomy and the effect of creating PLRI on compartment volume was investigated in 4 cadaveric elbows.

Results

All 4 patients had microtraumatic PLRI, and 2 patients had anconeus hypertrophy. Anconeus compartment pressures at rest and at 2-minutes postexercise were median 28.0 and 67.5 mm Hg, respectively, in the patients and mean 16.5 and 18 mm Hg, respectively, in the controls. Simultaneous fasciotomy and PLRI reconstructive procedures were performed in 2 patients, with outcomes showing full return to competition. Fasciotomy alone was performed in 2 patients to allow return to competition, with both requiring later reconstruction to address PLRI. Cadaver dissection revealed that the anconeus compartment was extremely small and that creation of PLRI reduced the direct volume of the compartment and increased the distance between the anconeus origin and insertion.

Conclusion

Our case series demonstrated that anconeus compartment syndrome can occur in upper limb-dominant athletes in the presence of PLRI and anconeus hypertrophy. Pain is relieved by fasciotomy, but definitive treatment of the underlying instability prevents further symptomatology.

Chronic exertional compartment syndrome of the forearm diagnosed in a wider spectrum of patients and not seldom with a history of the same diagnosis in the lower legs

Purpose

To identify patient characteristics associated with forearm chronic exertional compartment syndrome (CECS) and to demonstrate the distribution of intramuscular pressure (IMP) values at 1 min postexercise in a cohort of patients with exercise-induced forearm pain.

Methods

A consecutive series of 99 patients seeking orthopaedic consultation for chronic exertional forearm pain underwent IMP measurements between 2010 and 2023. The diagnosis of CECS was confirmed (n = 34) or ruled out (n = 65) based on the patient's history, clinical examination and IMP measurements.

Results

There were significantly more male patients in the CECS group than in the group of patients where the diagnosis was ruled out. Furthermore, a significantly higher proportion of the CECS patients had been previously treated for CECS of the lower legs. The most common occupation was office worker (21%), followed by craftsperson (18%). The most common main physical activities were strength training (21%) and cycling (15%). The median (range) 1-min postexercise IMP values for patients with CECS were 34 (23-68) mmHg for the flexor compartment and 32 (25-67) mmHg for the extensor compartment.

Conclusion

This study demonstrates a more general population of CECS patients compared to previous studies. Notably, more than a fifth of the CECS patients had previously been treated for CECS in the lower legs. Importantly, considering the 95% confidence interval for IMP values in patients without CECS, the most used IMP cutoff value for diagnosing CECS appears to be too high for the forearm compartments.

Level of Evidence

Level II.

Ultrasound-guided fasciotomy in forearm chronic exertional compartment syndrome: Preliminary results in 12 cases

INTRODUCTION

Forearm chronic exertional compartment syndrome is a rare condition in athletes and musicians who perform repeated prolonged forced gripping movements. It mainly affects young men, and presents with cramp-like pain, beginning on the anteromedial side of the forearm and progressively extending to the entire circumference, and may be associated with muscle weakness and neurologic symptoms. The objective of this study was to report preliminary results of ultrasound-guided fasciotomy in the treatment of forearm chronic exertional compartment syndrome.

MATERIAL AND METHODS

A single-center retrospective observational study was conducted. Forearm chronic exertional compartment syndrome was diagnosed on clinical presentation and pathological intramuscular pressure measurement, defined as >30 mmHg at 1 min after effort. The series comprised 7 men, with bilateral involvement. Mean age was 30 years. All patients were motorcyclists. The mean preoperative intramuscular pressure at 1 min after effort was 60.75 mmHg (range: 30-81 mmHg). The main study endpoint was change in pain on visual analogic scale. Secondary endpoints comprised patient satisfaction, change in competitive sports level, and time to return to sport. Complications were noted.

RESULTS

Six patients (12 forearms) were evaluated. Mean follow-up was 22.5 months (range: 3-48 months). Mean pain rating was 7.3/10 (range: 6-9) preoperatively, and 0/10 postoperatively. All patients were satisfied with the procedure. Mean time to return to sports was 25.5 days (range: 21-30 days). No patients decreased their competitive sports level after the procedure. One patient presented a postoperative hematoma, not requiring surgery.

CONCLUSION

Ultrasound-guided fasciotomy in the treatment of Forearm chronic exertional compartment syndrome is an innovative technique with promising preliminary results.

LEVEL OF EVIDENCE

IV; retrospective cohort.

Forearm compartment pressures and grip strength in elite motorbike racers with chronic exertional compartment syndrome

BACKGROUND

Remarkably little research has been published on chronic exertional compartment syndrome (CECS) of the forearm. This study investigated forearm flexor compartment pressure pre- and post-exercise in elite motorbike racers clinically diagnosed with CECS and assessed their grip strength before and after arm pump exercise.

METHODS

Elite motorbike riders with a clinical diagnosis of CECS of the right forearm when racing were recruited during the opening rounds of a British Superbike season. Their grip strength and forearm flexor compartment pressures were measured before and after a set exercise programme.

RESULTS

Of the 11 riders recruited to the study, 10 completed the full testing regime. The mean pre-exercise forearm compartment pressures [11.7 mmHg (range 7-17 mmHg)] significantly increased post-exercise [30.5 mmHg (range 15-45 mmHg)], with a mean increase of 18.80 mmHg (P < 0.0001). The mean pre-exercise grip strength [50.61 mmHg (range 37-66.7 mmHg)] decreased post-exercise to [35.62 mmHg (range 17.1-52.5 mmHg)], a mean decrease of 14.99 mmHg (P < 0.0001).

CONCLUSION

There is a statistically significant increase in the forearm flexor compartment pressures in elite motorbike racers with CECS, but with marked variability of these values. Grip strength decreases statistically significantly following onset of symptoms of CECS of the forearm.

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.

Recovery and Fatigue Behavior of Forearm Muscles during a Repetitive Power Grip Gesture in Racing Motorcycle Riders

Despite a reduction in the maximal voluntary isometric contraction (MVC_isom) observed systematically in intermittent fatigue protocols (IFP), decrements of the median frequency, assessed by surface electromyography (sEMG), has not been consistently verified. This study aimed to determine whether recovery periods of 60 s were too long to induce a reduction in the normalized median frequency (MF_EMG) of the flexor digitorum superficialis and carpi radialis muscles. Twenty-one road racing motorcycle riders performed an IFP that simulated the posture and braking gesture on a motorcycle. The MVC_isom was reduced by 53% (p < 0.001). A positive and significant relationship (p < 0.005) was found between MF_EMG and duration of the fatiguing task when 5 s contractions at 30% MVC_isom were interspersed by 5 s recovery in both muscles. In contrast, no relationship was found (p > 0.133) when 10 s contractions at 50% MVC were interspersed by 1 min recovery. Comparative analysis of variance (ANOVA) confirmed a decrement of MF_EMG in the IFP at 30% MVC_isom including short recovery periods with a duty cycle of 100% (5 s/5 s = 1), whereas no differences were observed in the IFP at 50% MVC_isom and longer recovery periods, with a duty cycle of 16%. These findings show that recovery periods during IFP are more relevant than the intensity of MVC_isom. Thus, we recommend the use of short recovery periods between 5 and 10 s after submaximal muscle contractions for specific forearm muscle training and testing purposes in motorcycle riders.

Muscle Fatigue When Riding a Motorcycle: A Case Study

This case study was conducted to assess muscle pattern, as measured by surface electromyography (sEMG), and its changes during a controlled superbike closed-road track training session. The sEMG signals were recorded unilaterally from biceps brachii (BB), triceps brachii (TB), anterior and posterior part of the deltoid (DA and DP respectively), flexor digitorum superficialis (FS), extensor carpi radialis (CR), extensor digitorum communis (ED) and pectoralis major (PM) during three rounds of 30 min. sEMG signals selected for analysis came from the beginning of the braking action to the way-out of the curves of interest. Considering the laps and rounds as a whole and focusing on the forearm muscles, ED was more systematically (84%) assigned to a state of fatigue than FS (44%) and CR (39%). On the opposite, the TB and DP muscles showed a predominant state of force increase (72%). Whereas the BB showed alternatively a state of fatigue or force increase depending on the side of the curve, when taking into account only the sharpest curves, it showed a predominant state of force increase. In conclusion, the fact that forearm muscles must endure a long-lasting maintenance of considerable activity levels explains why they easily got into a state of fatigue. Moreover, TB and DA are particularly relevant when cornering.

Endoscopic fasciotomy for chronic exertional compartment syndrome of the forearm: Systematic review of outcomes and complications

BACKGROUND

Endoscopic fasciotomy of the forearm for chronic exertional compartment syndrome (CECS) has gained popularity recently.

AIM

To systematically review the literature of endoscopic fasciotomy for CECS of the forearm, aiming to assess the outcomes and complications of the different endoscopic fasciotomy techniques described in the literature.

METHODS

On January 18, 2021, PubMed and EMBASE were searched by 3 reviewers independently, and all relevant studies published up to that date were considered based on predetermined inclusion/exclusion criteria. The subject headings “endoscopic fasciotomy” and “compartment syndrome” and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.

RESULTS

A total of seven studies including 183 patients (355 forearms) were included. The mean age of the patients was 31.2 years (range: 15-42 years). The postoperative follow-up duration ranged from 6 wk to 4.9 years. All patients were able to return to sport activities between postoperative weeks 1 to 8. Recurrence of the compartment syndrome occurred in three patients, giving a rate of 1.6% per patient and 0.8% per forearm. The overall complication rate was 8.7% per patient, and 4.5% per forearm. The most common reported complication was hematoma (7 forearms; 2.0%).

CONCLUSION

Endoscopic fasciotomy for CECS of the forearm has favorable short- and mid-term outcomes with very low recurrence and complication rates. This, however, needs to be confirmed in larger, long-term follow-up, prospective, comparative studies between open, mini-open and endoscopic fasciotomy techniques.

Epidemiology of upper limb chronic exertional compartment syndrome (CECS) in the French Motorcycle Federation racers: Results of a national questionnaire-based study

Upper limb chronic exertional compartment syndrome (CECS) has been described in amateur and professional motorcycle racers, but there is no published data about its prevalence. The purpose of this study was to define the awareness, prevention and prevalence of this syndrome in licensed motorcycle racers in competition in France. Secondary purposes were to determine the functional impact of CECS and post-treatment outcomes. The 20,641 licensed racers in competition of the French Motorcycle Federation were sent a self-assessment questionnaire about upper limb pain and CECS physical examination findings, functional impact and treatment outcomes. The satisfaction level was assessed after each type of treatment. Acceptability rate was 6.35% with 1311 racers responding. CECS was unknown by 29% of racers. Prevention methods were unknown by 10% of racers. Less than 50% of racers modified their bikes. The prevalence of upper limb CECS in competitive racers was 9%: 8.7% forearm, 0.2% thenar, 0.1% hypothenar and 0.4% first dorsal interosseus compartments. The prevalence was 16% in international level racers, 11% in national level racers and 7.3% in regional level racers. A quarter of racers were satisfied or very satisfied with the outcomes of conservative therapy and rehabilitation. Only 67 racers underwent surgical treatment for their upper limb CECS: 31 by open fasciotomy, 23 by minimally invasive fasciotomy and 13 by endoscopy-assisted compartment release. In these 67 racers, the mean visual analog score for pain improved significantly (p < 0.001 95% CI [3.1-4.5]) with 81% satisfied or very satisfied with surgery outcomes. This epidemiologic self-assessment questionnaire for upper limb CECS is a new concept. This study screened for CECS and offer information regarding evaluation, treatment, and management.

Forearm muscles fatigue induced by repetitive braking on a motorcycle is best discriminated by specific kinetic parameters

Maneuvering a motorcycle in racing conditions or for prolonged time is sufficiently demanding that on many occasions forearm muscles reach a state of functional failure when riders cannot properly brake or operate the throttle. This study intends to discriminate which ones of the several dynamometric parameters used in the literature to characterize the Force-time (F-t) curve during voluntary contractions are more sensitive to neuromuscular fatigue in simulated motorcycle-riding conditions. Thirty-three adults performed an intermittent fatiguing protocol (IFP) that simulated the brake-pulling and throttle-twisting actions, by using a hydraulic system equipped with a pressure sensor. Sixty pressure-time (P-t) curve parameters, including the rate of pressure development (RPD) and area under the curve were measured to characterize the time course of the braking maximal voluntary contraction (MVC). Two types of variables were used to analyze the P-t curve: 1) Times interval (from 0 to 30-50-100-500-1000 and 2000 ms); 2) Percentages of MVC (10-30-60-90%MVC). Overall significant (p ≤ 0.05) fatigue-related declines were observed only at time intervals longer than 100 ms and contraction intensities higher than 30%MVC. Strong and significant linear declines (p < 0.001) were observed at 500 ms and 1 s for normalized pressures, as well as for the ratio RPD_60%MVC/MVC (p < 0.003) throughout the IFP. Our results suggest considering RPD at time windows of 0–500 ms and 0–1 s, and contraction intensities comprised between 30% and 60% of MVC, as more suitable criteria to study fatigue-related decrements in performance rather than the classical MVC force.

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

Chronic Exertional Compartment Syndrome of the Forearm: Mini-invasive Technique Using an Endoscopic Soft Tissue Release System

Chronic exertional compartment syndrome of the forearm is a rare disease characterized by the recurrent onset of forearm pain and progressive weakness during exertion. Over the years many surgical techniques have been reported in literature: wide-open fasciotomy, mini-open fasciotomy, fasciotomy associated with fasciectomy, and mini-invasive endoscopic fasciotomy. Compared with traditional open techniques, mini-invasive techniques are characterized by minimal tissue trauma, less postoperative pain, faster recovery to normal activity and better esthetical result. We describe a mini-invasive endoscopic technique for the treatment of forearm chronic exertional compartment syndrome using the SmartRelease endoscopic tissue release system (MicroAire).

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.

Endoscopic fasciotomy for chronic exertional compartment syndrome of the forearm: Clinical results of a new technique using an endoscopic carpal tunnel release device

Exertional compartment syndrome of the forearm is a rare pathology, occurring almost exclusively in motorcycle racers. The results of endoscopic techniques are similar to those of open fasciotomies, but they are less invasive and leave smaller scars. The aim of our study was to present a new endoscopic technique for superficial fasciotomy using the Agee® system and to describe the results. This was a single-center, retrospective descriptive study of 21 patients (36 forearms) operated on between 2006 and 2016. All patients but one were competitive motorcycle racers. The mean operating time was 38.2min (standard deviation (SD), 10.5min). The QuickDASH score was 23.3±10.2% preoperatively versus 1±2% postoperatively (mean±SD). Among the 18 patients who came back for a follow-up visit after 4.9±2.7 years, 17 (94%) were satisfied or very satisfied. The mean time before returning to sport was 4.3 weeks (SD, 1.8 weeks), 9 patients (50%) at the same level as before surgery, 8 (44%) at a higher level, and one at a lower level. There were a few minor complications (superficial vascular lesions, hematoma, transitory hypoesthesia) and symptoms recurred in two patients. Our technique yields outcomes similar to those of other published endoscopic procedures and allows early return to sport. It has the advantage of being based on the Agee endoscope, which is commonly used to treat carpal tunnel syndrome, making the procedure easy to master.

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.

Upper Extremity Compartment Syndrome in a Patient with Acute Gout Attack but without Trauma or Other Typical Causes

We report the case of a 30-year-old Polynesian male with a severe gout flare of multiple joints and simultaneous acute compartment syndrome (ACS) of his right forearm and hand without trauma or other typical causes. He had a long history of gout flares, but none were known to be associated with compartment syndrome. He also had concurrent infections in his right elbow joint and olecranon bursa. A few days prior to this episode of ACS, high pain and swelling occurred in his right upper extremity after a minimal workout with light weights. A similar episode occurred seven months prior and was attributed to a gout flare. Unlike past flares that resolved with colchicine and/or anti-inflammatory medications, his current upper extremity pain/swelling worsened and became severe. Hand and forearm fasciotomies were performed. Workup included general medicine, rheumatology and infectious disease consultations, myriad blood tests, and imaging studies including Doppler ultrasound and CT angiography. Additional clinical history suggested that he had previously unrecognized recurrent exertional compartment syndrome that led to the episode of ACS reported here. Chronic exertional compartment syndrome (CECS) presents a difficult diagnosis when presented with multiple symptoms concurrently. This case provides an example of one such diagnosis.

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.

The Management of Extensor Mechanism Disruption After Total Knee Arthroplasty: A Systematic Review

We performed a literature search on PubMed, Web of Science, Science Direct/Scopus, Google Scholar, and Google to evaluate results of several techniques to manage disruption of the extensor mechanism after total knee arthroplasty. Different methods to manage extensor mechanism disruption are available at present, with no level I studies informing surgeons in an evidence-based fashion. Primary repair is not indicated. Allograft reconstruction could be effective, providing that appropriate surgical technique and allograft tensioning are implemented.

Motorcycle racer with unilateral forearm flexor and extensor chronic exertional compartment syndrome

We discuss a case of a 26-year-old man, a motorcycle racer, who presented with progressive pain, weakness and swelling of his right forearm and loss of power in his index finger, experienced during motor racing. Chronic exertional compartment syndrome (CECS) of both flexor and extensor compartments of his forearm was diagnosed by dynamic intracompartmental muscle pressure measurements. After fasciotomies, all symptoms were resolved and the patient was able to improve on his preinjury racing skills, without any limitations. A literature review and a surgical 'how-to' for correct release of the extensor and deep flexor compartments of the forearm are provided.

Surgical Decompression of Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Racers: Comparative Long-term Results of Wide-Open Versus Mini-Open Fasciotomy

OBJECTIVE

To compare the long-term results of 2 surgical techniques for forearm chronic exertional compartment syndrome (CECS) in professional motorcycling racers and to study a new diagnostic variable for CECS, TRest.

DESIGN

Retrospective case series.

LEVEL OF EVIDENCE

4.

SETTING

University Hospital.

PARTICIPANTS

Thirty-four patients identified from a surgical database who had been operated on for upper-limb CECS.

INTERVENTIONS

The purpose of the study was to report and compare the long-term results of 2 surgical techniques using fasciotomies [wide-open fasciotomy (WOF) versus mini-open fasciotomy (MOF)] for forearm CECS in professional motorcycling racers.

PATIENT CHARACTERISTICS

Pain [visual analog scale (100-point scale)] and functional scores (Quick-DASH) at 3 months after surgery and at regular intervals during clinical visits. Surgical complications: Level of satisfaction with the outcome. Time to return to full activity after surgery.

RESULTS

Thirty-four racers, 22 with bilateral involvement (n = 56), were diagnosed with CECS and were treated either with WOF (n = 24) or MOF (n = 32) depending on the surgeon's indication. Mini-open fasciotomy was usually selected in cases who need a faster recovery because of competition schedule. Visual analog scale and Quick-DASH improved 63 and 73 points, respectively (P < 0.001) with no significant difference between both surgical methods (P = 0.512). Both WOF and MOF were equally effective. Ninety-four percent of the patients were satisfied after 45.35 ± 12 months of follow-up, with no significant difference between surgical groups (P = 0.642). The time to return to full activity was 2.7 ± 1 week, also with no significant difference (P = 0.544). The time between when the stress testing was halted for pain and the return to baseline pressure (TRest) was superior to 15 minutes (defined as the mean minus 2 SDs) in 100% patients.

CONCLUSIONS

Surgical open or mini-invasive fasciotomy is equally successful in motorcycling racers with forearm CECS. Although the sensitivity of TRest is quite high in our series, further studies are still needed to validate its diagnostic value.

CLINICAL RELEVANCE

Surgical open or mini-invasive fasciotomy is equally successful in motorcycling racers with forearm CECS.

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.

Chronic exertional compartment syndrome of the forearm in elite rowers: a technique for mini-open fasciotomy and a report of six cases

Chronic exertional compartment syndrome (CECS) of the forearm may occur in sports requiring prolonged grip strength. CECS is a function of increasing pressure following muscle expansion within an inelastic tissue envelope resulting in compromise of perfusion and tissue function. Typical symptoms are pain, distal paraesthesia and loss of function. The condition is self-limiting and resolves completely between periods of activity. With no effective medical treatment, the gold standard remains four compartment open fasciotomy (Söderberg, J Bone Joint Surg Br 78(5):780-2, 1996; Wasilewski and Asdourian, Am J Sports Med 19(6):665-7, 1991). Minimally invasive techniques have been described (Croutzet et al., Tech Hand Up Extrem Surg 13(3):137-40, 2009) but have a risk of neuro-vascular injury, especially to the ulnar nerve while releasing the deep flexor compartment. We present a safe technique used with six elite rowers for mini-open fasciotomy to minimise scarring and time away from training while reducing the risk of neurovascular injury.

A single volar incision fasciotomy will decompress all three forearm compartments: a cadaver study

INTRODUCTION

Although there are three distinct compartments of the forearm, the typical approach for decompression of forearm compartment syndrome is a single incision fasciotomy of the volar compartment. This study had two purposes. The first purpose of this study was to investigate the compartment pressure changes within the forearm compartments following the creation of an acute compartment pressure using fresh-frozen cadaver forearm specimens. The second purpose was to compare the compartment pressure changes of the volar, dorsal, and mobile wad compartments at frequent intervals following a compartment fasciotomy of the forearm.

MATERIALS AND METHODS

An experimental study of a laboratory model of acute forearm compartment syndrome was performed at a level-one, university-based trauma centre. Eight non-embalmed human forearms from 5 male and 3 female donors with an average age of 71 years (range, 51-91) were used. Compartment pressures in the volar, dorsal, and mobile wad compartments were recorded both before fasciotomy and 1, 10, 20, and 30 min after fasciotomy.

RESULTS

A single incision volar fasciotomy was sufficient to decrease the elevated compartment pressures in the volar, dorsal and mobile wad compartments to near-baseline levels after 10 min. The mean compartment pressures 30 min post-fasciotomy in the volar, dorsal, and wad compartments were 2, 4, and 3 mmHg, respectively.

DISCUSSION

In a laboratory model of an acute forearm compartment syndrome, a single compartment fasciotomy may be sufficient to decrease compartment pressures in the non-released compartments (dorsal and mobile wad). Further study is necessary before changes in clinical management can be recommended.

Long-term results of surgical decompression of chronic exertional compartment syndrome of the forearm in motocross racers

BACKGROUND

Chronic exertional compartment syndrome (CECS) is occasionally observed in the forearm flexor muscles of motocross racers. Long-term results of fasciectomy and fasciotomy for this syndrome are scarce.

PURPOSE

To study the long-term effects of 2 surgical techniques for forearm flexor CECS.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A database of patients with forearm CECS who underwent surgery was analyzed. Long-term pain reduction (visual analog scale [VAS], 0-100) and efficacy were evaluated using a questionnaire.

RESULTS

Data of 24 motocross racers were available for analysis. Intracompartmental pressures during rest, during provocation, and after 1 and 5 minutes of provocation were 15 ± 4, 78 ± 24, 29 ± 10, and 25 ± 7 mm Hg, respectively. Painful sensations in the forearm were reduced from 53 to 7 (median VAS; P < .001). Both fasciectomy (n = 14) and fasciotomy (n = 10) were equally effective. More than 95% (23/24) of the patients were satisfied with the postoperative result after 5 ± 2 years' follow-up.

CONCLUSION

Surgical fasciotomy and fasciectomy of the forearm flexor compartment are equally successful in motocross racers suffering from forearm CECS.