ANTERIOR TIBIAL SYNDROME AND REYNAUD''S DISEASE

ANTERIOR TIBIAL SYNDROME

& REYNAUDS DISEASE

MODERATOR:

PROF .DR.K.PRAKASAMM.S Ortho, D.Ortho, DSc (HON)

Director & HOD

ANTERIOR TIBIAL

SYNDROME

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.

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.

• 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.

PathogenesisUnaccustomed exercise

Muscle trauma of anterior muscles of leg

Pressure inceases with in the anterior compartment of leg obstructing venous out flow

Ischaemic necrosis

• Spasm of anterior tibial artery may occur.

• Common peroneal nerve is involved by

compression

Clinical featuresEARLY 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.

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.

• 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.

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.

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.

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.

• Identify the superficial

peroneal nerve and

inter-muscular septum .

• Pass a fasciotome in the

line of anterior tibial

muscles.

• 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.

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

• Skin retraction to allow

fasciotomy under direct

vision.

• Wound closure after

release

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.

REYNAUDS DISEASE

DEFENITION

• Episodic digital ischemia manifested clinically

by the sequential development of digital

blanching ,cyanosis, and rubor of the

fingers/toes after the cold exposure.

CLASSIFICATION

• Primary Raynaud’s / Raynaud’s disease the

causes is not known.(Idiopathic)

• Secondary Raynaud’s / Raynaud’s

phenomenon where the causes are known.

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

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 tips entire finger all fingers in subsequent

attacks

• 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%

SECONDARY REYNAUDS DISEASE

• Due to underlying disease

1. Collagen vascular disease-

Scleroderma

Systemic Lupus Erythramatosis (SLE)

Rheumatoid Arthritis (RA)

Diabetis Mellitus

2. Arterial occlusive disease

• Thromboangitis obliterans

• Acute arterial occlusion

• Thorasic outlet syndrome

4. Neurologic disorders

• Intervertebral disc disease

• Syringomyelia

• Spinal cord tumour

• Stroke

5. Blood dyscrasias

• Cold agglutinins

• Cryoglobulinemias

• Myeloproliferative disorders

• Waldenstrom’s macroglobulinemia

6. Trauma

• Vibration injury

• Electric shock

• Cold injury

• Typing

7. Drugs

• Ergot derivatives

• Methyl sergide

• Bleomycin

• Vinblastin

• Cisplatin

Clinical features or Raynaud’s

• 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

CynosisIschemia

PallorVasospasm Rubor

Clinical Features:

• 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.

Differential Diagnosis

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.

DIAGNOSIS

• Raynaud’s 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.

NOVEL TECHNIQUES…

MANAGEMENT

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

Treatment

• Secondary Raynaud’s: Treatment of the underlying

disease

• Primary Raynaud's: Avoiding triggers.

– Extreme Cold Exposure

– Caffeine

– Coffee

– Avoidance of Emotional Stress

Emergency Care:

– Allow slightly warm water to run over the affected digits

and gently massage the area.

– Continue this process until the white area returns to its

normal, healthy colour.

– Place the affected digits in a body cavity—armpit, crotch,

or even the mouth.

– Vigorous hand movement will allow the blood

circulation to increase

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 – In patients with systemic sclerosis and

digital ulcers

• Surgery:

– Cervico dorsal sympathectomy

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,

THANK YOU!