tendinopathy and compartment syndrome

Question 1

what is the function of a tendon and what are they made up of?

Answer 1

• Transmits force from muscle to achieve movement
• Parallel collagen fibrils with tenocytes
• Surrounded by paratenon / sheath
• Largely avascular, nutrition via paratenon

Question 2

name some risk factors for developing tendinopathy

Answer 2

Age
Chronic Disease
Diabetes, Rheumatoid Arthritis
Adverse Biomechanics
Repetitive Exercise
Recent increase in activity
Quinolone Antibiotics

Question 3

Describe the pathology in tendinopathy

Answer 3

• Probably not inflammation – tendinosis not tendinitis
• Deranged collagen fibres / Degeneration with a scarcity of inflammatory cells
• Increased vascularity around the tendon
• Failed healing response to micro tears
• Inflammatory mediators released IL-1, NO, PG’s – cause apoptosis, pain and provoke degeneration through release of matrix metalloproteinases

Question 4

list some treatments for tendinopathy

Answer 4

NSAIDs, activity modification, physio, GTN patches, extra-corporeal shock therapy, surgery (if others fail)

Question 5

define compartment syndrome

Answer 5

Elevated interstitial pressure within a closed fascial compartment resulting in microvascular compromise. Common sites are the forearm, leg and thigh. It is an Orthopaedic emergency: risk of loss of limb or life

Question 6

describe the pathophysiology of compartment syndrome

Answer 6

• Pressure within the compartment exceeds pressure within the capillaries
• Muscles become ischemic and develop oedema through increased endothelial permeability
• Ischaemic nerves become neuropraxic (where there is a temporary loss of motor and sensory nerve function due to blockage of nerve conduction). This may recover if relieved early, permanent damage may result after as little as 4 hours
• Muscle swelling
• Increased permeability – fluid leaks into interstitial space
• Increased pressure
• Autoregulatory mechanisms overwhelmed
• Muscle necrosis and myoglobin release

Question 7

give some causes of compartment syndrome

Answer 7

Internal Pressure
o	Trauma – fractures, entrapment
	Bleeding
o	Muscle oedema / myositis
o	Intracompartmental administration of fluids / drugs
o	Re-perfusion – vascular surgery
External compression
o	Impaired consciousness / protective reflexes
	Drug / alcohol misuse
	Iatrogenic
o	Positioning in theatre - lithotomy
o	Bandaging / casts
o	Full thickness burns

Question 8

what are the clinical features of compartment syndrome

Answer 8

pain out of proportion to that expected from the injury
o Pain on passive stretching of the compartment
o Pallor
o Parathesia (late sign)
o Paralysis
o Pulselessness (late sign)

Question 9

where would you not be able to do a clinical diagnosis of compartment syndrome

Answer 9

if patient had an impaired consciousness level. Measure the compartment pressure.

Question 10

how would you treat compartment syndrome

Answer 10

• Urgent!
• Open any constricting dressings / bandages
• Reassess
• Surgical release (if removing pressure has not made a difference)
• Later wound closure
• Skin grafting / Plastic surgery input