3. DEFENITION
⢠A syndrome consisting of ischcaemic necrosis of the
muscles of the anterior tibial compartment of the leg,
with a lesion of the anterior tibial nerve.
4. INTRODUCTION
⢠The phrase the "anterior tibial syndrome" was first
used to describe a condition observed in healthy
young men.
⢠The features were pain in the front of the leg followed
by ischaemic necrosis of the anterior tibial group of
muscles.
5. ⢠The condition was first mentioned by P. R. Vogt.
⢠It is occurring in fit young men.
⢠During or after strenuous physical activity such as a
game of football, marching, or jumping, -pain
develops in the anterior tibial region.
7. ⢠Spasm of anterior tibial artery may occur.
⢠Common peroneal nerve is involved by
compression
8. Clinical features
EARLY STAGE
⢠Intense pain in the front of the leg, shortly after exercise.
⢠The pain does not relieved on rest .
⢠Followed by tenderness on pressure over the underlying
muscles, which feel firm, redness of the overlying skin, and
slight local oedema.
9. STAGE OF PARESIS
⢠If the condition is not relieved the affected
muscles become paralysed and the patient is
unable to dorsi-flex the foot or toes. (paresis )
⢠Foot-drop may not be obvious because of
contracture of the muscles.
⢠Usually confined to one leg.
10. ⢠All muscles of the anterior tibial group may
not be equally affected.
⢠Tibialis anterior and extensor hallucis longus
are involved
⢠But extensor digitorum longus may be only
partly affected.
11. Predowitz etal Diagnostic criteria for anterior tibial
syndrome
⢠Pre - exercise resting pressure of 15 mm of Hg or
more.
⢠Pressure of 30 mm 0f Hg or more after 1 minute of
exercise.
⢠Pressure of 20 mm of Hg or more after 5 minutes of
exercise.
12. TREATMENT
⢠This condition can be prevented by graduated
physical training. Or
⢠To stop complete athletic activities.
⢠When the full blown syndrome occurs Surgical
decompression of the anterior compartment
should be executed as an emergency procedure.
13. Single incision fasciotomy
⢠Anterior and lateral
compartment s are released
by a same incision
⢠5 cm longitudinal incision
half way between the fibula
and the tibial crest.
14. ⢠Identify the superficial
peroneal nerve and
inter-muscular septum .
⢠Pass a fasciotome in the
line of anterior tibial
muscles.
15. ⢠In the lateral compartment
,run the fasciotome
posterior to the superficial
peroneal nerve in line with
the fibular shaft.
⢠After releasing the
compatment
⢠Close the skin by sutures.
16. Double mini incisional fasciotomy Mouhsine
etal
⢠Without use of tourniquet
⢠Make two vertical incisions of 2 cm size with 15 cm
distance
⢠Development of subcutaneous flap with blunt
dissection
17. ⢠Skin retraction to allow
fasciotomy under direct
vision.
⢠Wound closure after
release
18. After treatment
⢠Early range of motion exercise are encouraaged
⢠Weight bearing on tolerance - crutches are allowed the
day after surgery.
⢠Crutches are discarded when walking without difficulties.
⢠Jogging is allowed at 2-3 weeks if swelling and
tenderness are absent.
20. DEFENITION
⢠Episodic digital ischemia manifested clinically
by the sequential development of digital
blanching ,cyanosis, and rubor of the
fingers/toes after the cold exposure.
21. CLASSIFICATION
⢠Primary Raynaudâs / Raynaudâs disease the
causes is not known.(Idiopathic)
⢠Secondary Raynaudâs / Raynaudâs
phenomenon where the causes are known.
22. PATHOGENESIS
Exaggerated Vasomotor Response
Expose to cold /
triggering factor
Digital arteries at
fingers and toes
vasospasm
Become pale, less
blood flow and low
O2 supply
Capillaries/venules
dialate
Cyanosis due to
deoxygenate blood
Rewarming-
(arteries dilate)
Blood flow increase,
high O2 supply
Reactive
hyperemia- Color
change to bright
red
Affected area is
warm and
throbbing pain
23.
24. PRIMARY REYNAUDS DISEASE
⢠Idiopathic
⢠50 % of reynauds include primary
⢠It often develops in young women in their teens and early
adulthood.
⢠Male : female = 1:5
⢠Age- between 20 & 40 years
⢠Figers > Toes
⢠One or 2 finger tipsď entire finger ď all fingers in subsequent
attacks
25. ⢠Rarely ear lobes/tip of the nose.
⢠Smoking worsens frequency and intensity of attacks.
⢠Caffiene also worsens the attacks.
⢠Associated disease: migrane and angina (vasospstic
disorders)
⢠Spontaneous improvement in 15%
⢠Progressive disease in 30%
30. Clinical features or Raynaudâs
⢠Primarily affects fingers
⢠Episodes precipitated by cold exposure
and emotional stress
⢠Episodes accompanied by pain with or
without numbness
⢠Pulses present
Initial
ischaemia
Pallor
Cyanotic
phase
Blue
Hyperaemic
phase
Red / purple
32. ⢠Chronic, recurrent cases of Raynaud phenomenon can result
in atrophy of the skin, subcutaneous tissues , and muscle.
⢠In rare cases it can cause ulceration and ischemic
gangrene.
34. Acrocyanosis
⢠Persistent, painless, symmetric cyanosis of the hands, feet, or
face
⢠Caused by vasospasm of the small vessels of the skin in response
to cold.
⢠The digits and hands or feet are persistently cold and bluish,
sweat profusely, and may swell.
⢠Cyanosis persists and is not easily reversed,
⢠Trophic changes and ulcers do not occur,
⢠Pain is absent.
⢠Pulses are normal.
35. DIAGNOSIS
⢠Raynaudâs phenomenon can be diagnosed on clinical
grounds.
⢠Imaging studies, including thermography, isotope studies,
and arteriography can be done .
⢠None has proven superior to clinical assessment.
⢠However, patients with a fixed, nonreversible, cyanotic
lesion require further evaluation of the vasculature.
38. Safety Measures
⢠Avoiding direct contact with frozen foods or cold drinks
⢠Insulation against cold and local warming, including gloves
⢠Heavy socks and electric and chemical warming devices
⢠Avoiding smoking
⢠Discontinuing drugs that may provoke vasospasm
39. Treatment
⢠Secondary Raynaudâs: Treatment of the underlying
disease
⢠Primary Raynaud's: Avoiding triggers.
â Extreme Cold Exposure
â Caffeine
â Coffee
â Avoidance of Emotional Stress
40. Emergency Care:
â Allow slightly warm water to run over the affected digits
and gently massage the area.
â Continue this process until the white area returns to its
normal, healthy colour.
â Place the affected digits in a body cavityâarmpit, crotch,
or even the mouth.
â Vigorous hand movement will allow the blood circulation
to increase
41. Drug Therapy:
⢠Calcium Channel Blockers like Nefidipine can be given
⢠Sildenafil can improve the microcirculation and
relieves symptoms in patients with Secondary
Raynaud's phenomenon resistant to vasodilator therapy
⢠Topical nitroglycerin (1% or 2%) local application.
⢠N-acetylcysteine â In patients with systemic sclerosis and
digital ulcers
43. References
⢠Mercer text book of orthopaedics 8th edition
⢠Campbells operative orthopaedics 11 th Edition
⢠Campbells operative orthopaedics 12 th Edition
⢠Crawford Adams outline of orthopaedics
⢠Natarajan text book of orthopaedics
⢠D C Watson ; British medical journal,Anterior
Tibial syndrome following arterial
embolism:1412-1413 June 1955,