DOCTOR’S CORNER with Dr JOSEPH KABUNGO
Many times injuries happen in contact sport, and it is seldom thought that such injuries can present with complications either in the immediate or acute phase or indeed after some time. I mentioned one complication last Sunday arising as a result of thigh muscle injuries and this had to deal with the problem of acute compartment syndrome.
It is important that injuries happening in contact sport are followed up from the time they happen until the player has fully recovered. Though not so many complications occur when players suffer from muscular injuries in contact sport, it is always saddening when complications arise.
Complications might be caused directly by the injury itself or might be associated with the treatment of that particular injury. It becomes important not to trivialize injuries happening in muscles such as the calf muscle or the muscles of the thigh because of the complications that might arise.
It is always interesting when sports men encounter situations or complications arising as a result of injury. Injuries are the most worrisome scenarios, which athletes go through time and again. It is inevitable to have an injury free sports career in the majority of professional sports men.
Young football players are always participating in sport especially football in our country and they definitely suffer injuries of various kinds .It is then necessary that such players are carefully examined and appropriate treatment given in order to avoid some complications that might arise.
Many football players will actually attest to the feeling they might have experienced especially on the leg after applying a crepe bandage or strapping too tightly to the leg. The pain is so intense such that the only way to relieve the paint is only through removal of the applied bandage or strapping.
In the same vein very tightly applied plaster of Paris to a fractured leg in a football player can cause a lot of pain to an individual if not correctly applied especially if the reaction to the fracture and tissue damage is not controlled.
Fractures can arise as a result of sport participation or from many other causes unrelated to sport. I think someone might wonder just as to why the plaster can cause so much pain instead of acting as a measure to help in fracture healing and reducing the pain. Am not trying to insinuate that it is wrong to apply a POP to a fracture but just want to bring out and share with you, what is meant when people discuss the acute compartment syndrome in relation to sport.
The application of a plaster of Paris to a fractured leg or arm is just one example citing compartment syndrome, but muscle injuries can also lead to this sort of medical emergency.
I must admit that, through the last fourteen years, I have only encounter one real scenario of a patient with an acute compartment syndrome in the hospital setting though there have been many instances where I have had to loosen up the over tightened plaster or crepe bandage in a football player.
It must be appreciated that muscles of the thigh, leg, arm and forearm are arranged in groups, which are covered with a structure that is not elastic. This fibrous structure is what we call the fascia and it is very hard and has got no provision to enlarge or expand once there is an increase in pressure inside.
Pressure inside these muscle compartments can increase due to bleeding and to the fluid, which is produced as result of injury to the muscle .It can also be a resultant of obstruction in the blood flow that leads to this event. This sort of intramuscular bleeding is one example that I made when talking about thigh muscle contusions last Sunday.
Injury to the calf muscles and also the muscles of the thigh can have an acute compartment syndrome (ACS) arising as a complication. Am sure many have encountered a situation were you shake a coca cola bottle and know the amount of pressure that is created inside the bottle, especially the Coca-Cola of yester years.
This is similar to the pressure that is created in a muscular compartment in a confined space. It is called a compartment syndrome because it consists of symptoms that arise as a result of increase in pressure in the respective muscular compartment of a limb, either the arm or the leg.
It must be remembered that compartments which houses the muscle, have blood vessels and nerves passing though and all the symptoms are related to the obstruction or disturbances in the flow of blood and also transmission of the nerve impulses.
In acute compartment syndrome there is pain that arises due to obstruction of blood vessels resulting in reduced blood flow to the muscle. The reduction in the blood flow is what is known as ischemia in medical terms and the pain is referred to as ischemic pain.
The reason why excessive pain has to be taken seriously is the fear of an acute compartment syndrome that might lead to damage of the affected part and lead to permanent disability.
The other problem that might arise is the feeling of numbness in the affected leg because of nerve compression. The nerve compression might also lead to paralysis of the affected limb or leg.
Also the other notable feature of the acute compartment syndrome is the changes in skin color in the part just lying further down the affected part, which is refffered to as pallor.
It is common in a normal individual to feel the pulse of the wrist or indeed the foot but when there is compression of the artery supplying a particular limb the pulse will not be felt and this is referred to as pulselesness.
In short the components of compartment syndrome are referred to as the five P’s of compartment syndrome, and these are Pain, parasthesia (Numbness), Paralysis, Pallor and pulselesness. These are the features of a typical acute compartment syndrome.
It is also important that other causes of acute compartment syndrome apart from injuries or trauma to the muscle are mentioned. As mentioned above a POP which is tightly applied whilst the muscle is still reacting to injury will result in compartment syndrome.
This will be due to the rigid POP that will further complicate the already limited space in the muscle compartment. It is one of the reasons that before a POP is applied elevation of the limb must be done in order to limit tissue swelling and if the swelling is so marked, it must be allowed to get down or subside.
Other notable causes of acute compartment syndrome are bleeding in the muscle as a result of a contusion, obstruction of the venous drainage, burns, and certain drugs that inhibit blood clotting or anti-coagulants. This is the reason why an athlete taking drugs must tell the attending medical person that they are on one particular medication, which might be a risk factor.
It can be seen that acute compartment syndrome can be linked to the injury itself and also the treatment modalities adopted for that particular injury.
Treatment of acute compartment syndrome is critical to avoid the end stage damage to the body part affected. If the pressure is not relieved in acute compartment syndrome, the end result might be an amputation of the affected leg because of the death of the muscle and other body tissues.
Whenever an acute compartment syndrome is suspected there is need for immediate medical attention in a facility were surgery can be done to relieve the pressure.
The surgical procedure that will be done is called a fasciotomy because it involves the cutting of the fascia compartment that encloses the muscle. When this is done pressure is relieved and normal blood flow is established and the nerve supply is restored.
It must be mentioned that The PRICE (Pressure, Rest, Ice, Compression, Elevation) management of injured muscles of calf and the thigh must be started in the shortest possible time. The PRICE therapy mighty be the key to prevention of an Acute compartment syndrome and thereby preserve the leg and career of an individual. Though very rare, an acute compartment syndrome is a real disaster if it ever happens to an athlete…………
For questions and comments write to: Dr Kabungo Joseph. Email Address: zengajk@yahoo.com or kateulejk@gmail.com