Compartment Of Leg Research Articles

Distribution of the branches of common and superficial fibular nerves to peronei longus et brevis muscles. Use in the treatment of spasticity of fibular muscles

Beside the posterior leg compartment, spasticity of the hemiplegic patient can involve other muscle groups in the leg. Spasticity of the lateral compartment is responsible of a vertical clonus that may be confused with the clonus of the triceps surae (long fibular) or a transverse clonus (short fibular), and by the liveliness of the tendon reflex when striking their tendon. Beside recurrent botulinum toxin injections, this spasticity may be treated by a hyponeurotisation by partial section of the branches of the superficial fibular nerve to the muscle(s) concerned. Its technique has never been described. Twelve legs of formalin corpses have been dissected. The number of branches to PL and PB, their level of emergence from the common and deep fibular nerves, and their entry point into the muscle have been measured from the lateral femoral-tibial articular space (LTF). There was always a common trunk to the EDL and the EHL, arisen on average at 10.3 cm (8.2–13.6) from the LTF line. Six times out of 10 in addition to this common one (3), two (2) or three (1) additional branches to the EDL, arisen between 4.6 and 12 cm downstream the LTF line. Six times out of 10 in addition to this common trunk existed one (4) or two (2) additional branches to the EHL, arisen between 13 and 26 cm downstream the LTF line. This first study allow establishing the surgical technique of the hyponeurotisation of PL and PB muscles. The first results are presented.

Prevalence of Fibularis Tertius Muscle in Southeastern Indian Population: a Surface Anatomical Study

Background:Fibularis tertius (FT) is a variant muscle of the anterior compartment of leg which involves in dorsiflexion and evertion of the foot. Literature shows that the reported prevalence of FT ranges from 49-100%. This study investigates the prevalence of FT in South-eastern population of India using surface anatomy techniques in living subjects and comparing it with the studies available in the literature.Material and Methods:Study included the evaluation of 195 subjects from Year 1 & 2 medical students (102 females and 93 males) which correspond to 390 feet in total. The average age of the sample was 17.9 years, with lower and upper limits of 17 and 20 years, respectively. The presence of FT was identified with a standard palpation technique that determines the presence of muscle on the basis of the progression tests called F1, F2, and F3.Results:The total FT prevalence was found to be 52% of the sample. On the right foot, FT was found to be 26.6% in males and 24.6% in females and on the left foot, it was 27.2% in males and 25.6% in females. FT palpation criterion showed 0 (zero) cases for F1, 31 cases for F2 and 172 cases for F3.Conclusions:This surface anatomical study reports for the first time the FT prevalence in South-eastren population of India. Further studies on prevalence of FT are needed to understand its role in biomechanics and reconstructive surgeries of the ankle and foot.

Neuromotor response of the leg muscles following a supine, stand retraining with/without neuromuscular electrical stimulation training intervention for individuals with SCI: A case series.

The goal of this paper is to study the effects of supine and stand retraining (SRT) interventions with and without multi muscle neuromuscular electrical stimulation (NMES) on the neuromuscular EMG responses of the leg muscles for individuals with motor complete SCI during walking on a body-weight support (BWS) treadmill. The main outcome variables were EMG amplitude, integrated EMG and co-contraction indices (co-excitation and co-activation) collected during a 10-minute walking treadmill trial. Data was analyzed for the first, fifth and tenth minute of walking. Results showed that both Supine+NMES and SRT+NMES interventions increased spatial-temporal aspects of muscle activity (mean EMG amplitude and integrated EMG) of lower limb muscles. SRT+NMES (loading) showed greater gains in the proximal anterior leg compartments. On the contrary, SRT without NMES (SRT only) exhibited deterioration of activity within the same muscle groups. Co-contraction indices increased for both post-NMES interventions suggesting that task-specificity of training is important to achieve the fundamental reciprocal firing known to able-bodied gait. These results show that combination of NMES+loading during passive rhythmic gait will induce neuroplasticity in the lower limbs that ultimately provides a potential effective means to recover gait in individuals with SCI.

Accuracy of Palpation-Guided Catheter Placement for Muscle Pressure Measurements in Suspected Deep Posterior Chronic Exertional Compartment Syndrome of the Lower Leg

Background: A diagnosis of lower leg deep posterior chronic exertional compartment syndrome (dp-CECS) is made by a dynamic pressure measurement. The insertion of a pressure catheter is guided by anatomic landmarks (freehand) or by ultrasound. The catheter tip is ideally positioned in the tibialis posterior muscle (TP). The accuracy of in vivo catheter placement using lower leg magnetic resonance imaging (MRI) in healthy patients suspected of having dp-CECS has never been studied. Purpose: To analyze whether a freehand catheter insertion results in accurate positioning in the TP as confirmed by MRI in patients with suspected dp-CECS. Study Design: Case series; Level of evidence, 4. Methods: Catheters were inserted into central portions of the TP using a standard puncturing technique guided by lower leg anatomic landmarks. After timed muscle pressure measurements during a standard provocative treadmill running test, lower leg MRI scans were obtained and evaluated by 2 skilled radiologists. Catheter tip placement was termed accurate (in the TP), suboptimal (in the deep posterior compartment but outside the TP), or inaccurate (outside the deep posterior compartment). Results: Between March 2013 and September 2014, a total of 24 patients (8 male, 16 female; mean age, 30 years [range, 18-54 years]) underwent an intracompartmental pressure (ICP) measurement, followed by MRI. Cardinal symptoms were pain during exertion (20% very severe, 53% severe, and 20% moderate) and tightness (29% very severe, 43% severe). Symptoms were bilateral in 74% of patients. Nine of the 24 patients were diagnosed with dp-CECS based on elevated ICPs. Of the 24 patients, catheter tip placement was accurate in 10 (42%), whereas suboptimal placement was achieved in 9 (38%). Five procedures were inaccurate (transition zone between the deep and superficial compartments, n = 3; in the superficial lower leg compartment, n = 2). Signs of a hematoma were found in 38% of the patients, although there were no associated clinical symptoms. Conclusion: Palpation-guided placement of catheters for TP pressure measurements is suboptimal in more than half of the patients with suspected lower leg dp-CECS. Optimizing the pressure catheter tip positioning technique may improve diagnostic accuracy in dp-CECS.

Broadening the imaging phenotype of dysferlinopathy at different disease stages

MRI characterization of dysferlinopathy has been mostly limited to the lower limbs. We aimed to broaden the MRI description of dysferlinopathy and to correlate it with objective measures of motor dysfunction. Sequential whole-body axial MRI was performed in 27 patients with genetically confirmed dysferlinopathy classified according to disease duration. Spearman correlations of fatty infiltration scores versus Motor Function Measure (MFM) were calculated. Significant fatty infiltration was symmetrically present in early stages mainly in the posterior compartments of legs and thighs, thigh adductors, pelvic girdle, and some paravertebral muscles and the subscapularis. Later, fatty infiltration involved leg and thigh anterior compartments, arms and forearms, paravertebral, and trunk muscles. MRI infiltration score correlated positively with disease duration and negatively with MFM scale. We expand MRI characterization of dysferlinopathy and provide evidence for use of MRI scoring combined with motor functional scales to assess the natural course of disease. Muscle Nerve, 2016 Muscle Nerve 54: 203-210, 2016.

Single minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg.

BackgroundChronic exertional compartment syndrome (CECS) involves a painful increase in compartment pressure caused by exercise and relieved by rest, common in athletes. The most common site for CECS in the lower limbs is the anterior leg compartment. The aim of this study is to evaluate the outcomes of a single minimal incision fasciotomy in athletes and their capability to return to high level sport activity.MethodsThe study reports mid-term results in a series of 18 consecutive athletes with chronic exertional compartment syndrome of the leg who had undergone minimally invasive fasciotomy. Between 2000 and 2007, we prospectively enrolled 18 consecutive athletes (12 males and six females, median age 27 years) with unilateral or bilateral chronic exertional compartment syndrome undergoing unilateral or bilateral minimally invasive fasciotomy. Clinical outcomes were assessed with Short-Form Health Survey-36 (SF-36) and European Quality of Life-5 Dimension (EQ-5D) scale. The ability to participate in sport before and after surgery and the time to return to training (RTT) and to sport (RTS) were recorded.ResultsThe median follow-up after surgery was 36 months. Both questionnaires showed a statistically significant improvement (P < 0.0001) after surgery. At the time of the latest follow-up, 17 of 18 patients (94 %) had returned to pre-injury or higher levels of sport. Only one patient (6 %) returned to sport at lower levels than those of pre-injury status. The median time to return to training and to return to sport was 8 and 13 weeks, respectively. No severe complications or recurrence of the symptoms were recorded.ConclusionsMinimally invasive fasciotomy is effective and safe for athletes suffering from unilateral or bilateral chronic exertional compartment syndrome of the anterior and lateral compartments of the leg with good results in the mid-term.

The Efficacy of a Single-Incision Versus Two-Incision Four-Compartment Fasciotomy of the Leg: A Cadaveric Model.

Replicating an established cadaveric model, this study investigates the efficacy of single-incision and 2-incision fasciotomies to satisfactorily decompress all 4 compartments of the leg. We hypothesized that both techniques would adequately release each compartment and that a compartment syndrome could not be recreated in the deep posterior compartment after releases by either technique. Acute compartment syndrome was simulated in 8-paired, fresh-frozen human cadaver legs by infusing normal saline into all 4 compartments. Subsequent 4-compartment fasciotomies were performed on each pair using both techniques. After fascial release, the deep posterior compartment was reinfused in an attempt to recreate an acute compartment syndrome. Statistical analysis was performed using the Student t-test with significance set at a P value less than 0.05. Sustainable pressures greater than 60 mm Hg were established in all 4 compartments of each specimen. Postfasciotomy pressures were all reduced to less than 30 mm Hg using both single-incision and 2-incision techniques. There were no statistically significant differences in postrelease pressures between the 2 techniques in any compartment. The average postrelease pressure in the deep posterior compartment was 4.6 mm Hg (range 0-10 mm Hg) with the single-incision technique and 5.6 mm Hg (range 1-10 mm Hg) with the 2-incision technique (P = 0.44). After complete fasciotomies, it was not possible to recreate the elevated pressures of acute compartment syndrome in the deep posterior compartment of any specimen. A single-incision, 4-compartment fasciotomy is as effective as a 2-incision technique for release of acute compartment syndrome in this cadaveric model.

A Novel Method For Assessing Leg Compartmental Body Composition Using Dual Energy X-ray Absorptiometry

PURPOSE: Manual segmentation using dual energy X-ray absorptiometry (DXA) is a valid method for quantifying contralateral tissue asymmetries of the body but has not been used to quantify body composition in the ipsilateral upper leg compartments. The purpose of this study was to examine the reliability and validity of DXA to quantify fat and lean composition in the anterior and posterior compartments of the upper leg. METHODS: Twenty-one (10 male/11 female) college athletes (X[Combining Overline]age= 20±1y) were assessed for total and regional body composition. Segmentation of the anterior and posterior thigh compartments was accomplished by scanning participants lying on their right and left side. Each scan was manually segmented and analyzed by 3 technicians using custom regions of interest (ROIs) created from bony landmarks on the femur. Caudal and distal borders of the ROI were made at the level of the greater trochanter and lateral epicondyle. A line was drawn down the middle of the femur to create an anterior and posterior ROI to quantify tissue composition between compartments. To validate this new segmentation method, lateral scan measures were compared with total body frontal scan measures of upper leg compartments for fat, lean and total tissue masses. Independent t-tests assessed these compositional comparisons. Intra-class correlation coefficients (ICC) and coefficients of variation (CV) were calculated to assess reliability. RESULTS: All comparisons of total, lean and fat tissue masses between the frontal and lateral DXA scans were non-significant (p-value: 0.14 to 0.64). ICCs were high for all composition measures between- and within-testers, ranging from 0.983 to 0.999 and 0.954 to 0.999, respectively, with low variation across measures (all CVs: <5%). CVs between- and within-testers, respectively, for segmented total composition were ≤4.8% and ≤3.8% and compartmental composition were ≤3.5% and ≤2.7%. CONCLUSIONS: This study demonstrated that DXA measures using custom ROIs to assess anterior and posterior upper leg fat, lean, and total masses are valid and reliable. Future studies are needed to determine the clinical usefulness of these measures with regard to prevention or rehabilitation of sports-related injury. Funded by University of Minnesota CTRS Mini Pilot Funding Program

Hyperextension Varus Bicondylar Tibial Plateau Fracture Pattern: Diagnosis and Treatment Strategies.

The authors have identified a subset of bicondylar tibial plateau fractures with a hyperextension varus deformity (HEVBTP). The radiographic hallmarks of this pattern are (1) sagittal plane malalignment with loss of the normal posterior slope of the tibial plateau, (2) tension failure of the posterior cortex, (3) compression of the anterior cortex, and (4) varus deformity in the coronal plan. The purpose of this study was to describe this fracture pattern, to compare the associated injuries with non-HEVBTP fractures, and to suggest treatment strategies that may allow for improved reduction and stabilization. Retrospective Cohort Study. Level 1 trauma center. Preoperative radiographs and CT scans were reviewed in 208 patients who sustained 212 bicondylar tibial plateau fractures (OTA 41C). Twenty-five fractures in 23 patients fulfilled the radiographic criteria for HEVBTP fracture pattern. The remaining 187 bicondylar tibial plateau fractures were used as a control group. Initial spanning external fixation, followed by open reduction internal fixation and bone grafting with/without augmentation. Associated injury rate compared with OTA 41C patients without HEVBTP pattern, nonunion rates, and loss of reduction rates. Thirty-two percent of the HEVBTP fractures demonstrated significant associated injuries compared with 16% in the control group. The incidence of popliteal artery disruption requiring repair was 12% in the HEVBTP group compared with 1% in the control group. Patients with HEVBTP had either partial or complete peroneal nerve injury in 16% of cases (8% in control group) and 12% of patients developed a leg compartment syndrome (10% in control group). The HEVBTP pattern is a unique fracture. The surgeon must recognize the possible associated injuries that accompany this injury. We suggest fixation strategies that address this injury's individual components which may help to avoid failure. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Acute Exertional Compartment Syndrome in a Young Amateur Soccer Player: A Case Report.

We present a case of acute compartment syndrome of the lateral compartment of the lower leg, caused by strenuous eccentric exercise. The diagnosis can be made based on clinical findings, but ultrasound and MRI can be useful in recognizing this rare form of compartment syndrome.

The presence of a variant leg muscle, flexor digitorum accessorius longus (FDAL), causing tarsal tunnel syndrome, or posterior tibial neuralgia

The flexor digitorum accessorius longus (FDAL) muscle is a variant muscle located in the posterior compartment of the distal leg. It typically originates in the distal third of the leg and can have a variable proximal attachment to the tibia, fibula, tibia and fibula, the posterior intermuscular septum, or any of the musculature in the deep posterior compartment of the leg. The FDAL then courses posterior to the medial malleolus, enters the the tarsal tunnel (deep to the flexor retinaculum), and ends by inserting onto either the flexor digitorum longus tendon and/or the quadratus plantae muscle, which are located in the second muscular layer of the sole of the foot. The prevalence of the FDAL has been reported in 6% of asymptomatic individuals based on MRI studies or 2–12% of cadaveric studies.The presence of the FDAL has been identified as a cause of tarsal tunnel syndrome, a compression neuropathy of the tibial nerve and/or its branches that become compressed as they course deep to the flexor retinaculum. As the FDAL traverses the tarsal tunnel, it lies immediately superficial to the neurovascular bundle and can act as a space‐occupying lesion, entrapping the tibial nerve and causing numbness, pain, and paresthesias in the foot, ankle, and toes. This variant muscle is best visualized through the use of magnetic resonance imaging (MRI). While there are conservative treatments for tarsal tunnel syndrome, most often surgical intervention is needed to remove the FDAL, and the success of this operative procedure is often based on the extent of damage to the tibial nerve prior to surgery. This presentation will include a patient case and show examples of the FDAL muscle following cadaveric dissection and within MRI studies. Radiologists and surgeons should be aware of presence of the FDAL muscle when considering the etiology of tarsal tunnel syndrome.Support or Funding InformationThe research of Jordan V. Swearingen and Kyle D. Miller was supported by the West Virginia University Initiation to Research Opportunities (INTRO) Program.

A novel method to correctly place the fasciotomy incision for decompression of the anterior and peroneal compartments of the leg

Incorrectly placed fasciotomy incisions can lead to catastrophic complications in compartment syndrome. Two distinctly different techniques are widely practiced to decompress the anterior and peroneal compartments. In one technique the anterior compartment is decompressed directly, and then the peroneal via the inter-muscular septum, avoiding the peroneal perforators. The second technique relies on surface anatomy landmarks to place the skin incision immediately over the inter-muscular septum, and then the respective fascial envelopes are incised separately.A study in healthy active volunteers was conducted to explore the feasibility of a new technique for the placing the incision very accurately over the inter-muscular septum and so avoiding perforator vessels. Hypothesis The inter-muscular septum can be reliably identified using hand-held ultrasound, and confirmed with MRI. MethodsFourteen healthy active volunteers underwent hand-held ultrasound to identify the antero-lateral inter-muscular septum in the left lower limb, which was then marked using cod liver oil capsules. The positions of the anterior, septal and peroneal perforators were then identified using hand-held Doppler, and marked in the same way. MRI was then used to measure the relationship between the surface land marks, the septum (compared to its US position), and the relationship of the perforators themselves. ResultsHand held ultrasound was successful in identifying the position of the inter-muscular septum in healthy volunteers, as confirmed on MRI scanning. The position and number of peroneal and anterior perforators proved very variable. Direct decompression of the anterior compartment would result in the loss of all anterior perforators in all subjects. Decompression with the skin incision over the inter-muscular septum would not jeopardise any peroneal muscular perforators. ConclusionThis new technique enables decompression both the anterior and peroneal compartments through an accurately placed incision, sparing the greatest number of perforators. Two brief case histories in which the technique was used are presented.

Osteofascial compartment pressure measurement in closed limb injuries - Whitesides' technique revisited.

Regular monitoring of tissue compartmental pressures and hence a timely intervention in patients with impending compartment syndrome has been shown to prevent morbidity and permanent disability. Intra-compartmental pressure in flexor compartment of forearm and various compartments of legs following recent trauma presenting within 6h of injury was carried out in 30 subjects using Whitesides' technique and patients were classified into 3 categories for treatment purposes i.e., Category I: pressure <30mmHg, Category II: pressure 30-40mmHg and Category III: pressure >40mmHg. Category I had 17 subjects, Category II had 6 subjects whereas 7 subjects fell into Category III. 6 patients out of the 30 studied needed fasciotomy, out of which 5 had fair or good result. Whitesides' technique, though not much widely favoured, is a safe, inexpensive, easily assembled and reliable method for measurement of intra-compartmental pressure as a guide for decompression.

Unilateral Variation in Extensor digitorum longus muscle.

During a routine dissection of an adult embalmed male cadaver for educational purpose in the department of anatomy at AIIMS, New Delhi, India, a rare unilateral variation of extensor digitorum longus (EDL) was found which is a muscle of anterior compartment of the leg. There was a split tendon of EDL muscle in the anterior compartment of left leg which became a common tendon in front of the ankle joint. This common tendon of EDL muscle again divided into four slips and were inserted in to the lateral four toes. In the upper part of the leg, the anterior tibial vessel and deep fibular nerve lie between the EDL and tibialis anterior. Knowledge of this type of anomaly is useful in diagnosis and treatment of compartmental syndrome. One of the tendon from the split tendon of EDL muscle can be used as a graft in tendon replacement surgeries. The split tendon may also be capable for some precise movements of the toes.

Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg.

Surgical release of the anterior and lateral compartments of the lower leg has been shown to relieve the symptoms of chronic exertional compartment syndrome. We utilize a technique that allows the surgeon to perform anterior and lateral compartment fasciotomies through a single incision while safely identifying the superficial peroneal nerve. After positioning the patient supine on the operating table with the operative extremity prepared and draped, anatomic landmarks are identified on the patient's skin. The major steps of the procedure are (1) identifying the distal end of the fibula, anterior fibular diaphysis, tibial crest, fibular head, and lateral aspect of the patella; (2) drawing the skin incision, beginning 6 to 8 cm proximal to the distal end of the fibula centered between the tibial crest and anterior fibular diaphysis and extending it 6 cm proximally; (3) making a skin incision longitudinally and dissecting the subcutaneous tissue to allow identification of the fascia and superficial peroneal nerve; (4) performing gentle neurolysis; (5) identifying the anterior and lateral compartments, making small incisions in the fascia of each compartment, and then performing fasciotomy of the lateral and then anterior compartments while protecting the superficial peroneal nerve; and (6) irrigating the wound, closing it in layers, and applying a soft, compressive dressing. Postoperatively, the patient is allowed to bear as much weight as he or she can tolerate. Current literature indicates that good-to-excellent outcomes can be expected for 90% to 95% of patients treated with fasciotomy. Military personnel and patients with posterior compartment involvement may have less reliable outcomes.

An unusual calcific myonecrosis: a case report

Calcific myonecrosis is a rare painful, expansile, calcified mass that develops as a result of compartment syndrome in a muscle of lower extremity. Patient usually present several years after trauma as a mass typically in anterior compartment of leg which can be mistaken for soft tissue tumor. Imaging studies can aid in the diagnosis of this less known entity. However, diagnosis is confirmed by histopathologinal findings of linear calcification and central necrosis inside a cavity in a muscle. We report a rare case of calcific myonecrosis involving posterior compartment of leg in a forty three year old female who had presented with pain in right mid-calf region for two weeks. Color Doppler showed small cystic lesion with calcification suggestive of probable neurofibroma for which complete excicion of the lesion was done and diagnosis of calcific myonecrosis was made on histopathological examination. Keywords: Calcification, Myonecrosis, Trauma

The prevalence and pattern of acute compartment syndrome of the limbs in a private orthopedic and trauma center, Southeast, Nigeria: 8 years retrospective study

Background: Acute compartment syndrome of the limb is an orthopedic emergency. The leg compartments, usually following fracture of the tibia are most commonly implicated. Study Design and Setting: This is a retrospective study on the scope of compartment syndrome among patients with limbs traumas who were treated between October 2007 and September 2015 in a private orthopedic and trauma center situated in a highly populated south eastern Nigerian city. Patients and Methods: The medical records as well as data from the operation register master list of patients with limb injuries were studied. Limb injuries considered significant enough for in-hospital treatments with or without other associated system injuries were included while patients with any form of arterial disease or claudication were excluded. Results: A total of 1362 patients met the inclusion criteria. Fourteen patients (1.02%) had acute compartment syndrome. The commonest underlying pathology was fracture of the tibia in eight patients (57%). Two patients (14%) were due to tight traditional bone setters' splints and one (7%) was from burns eschar. There was a slight male predominance and young adults in their primes were mostly affected. Conclusion: Acute compartment syndrome of the limb is not very common. Early clinical diagnoses in the absence of the pressure monitoring equipment is recommended and emergency fasciotomies are necessary to salvage the limbs.

Intracompartmental pressure changes after anterolateral bridge plating of tibial fractures.

Compartment syndrome is one of the most devastating complications in orthopedics both for the patient and the treating physician. Among the many causes, trauma and its treatment are the most common reasons for compartment syndrome, which most frequently occurs in the lower leg following tibial fractures. Since bridge plating of difficult metadiaphyseal tibial fractures is becoming increasingly popular, serious concerns have been raised about the increased intracompartmental pressures and possible compartment syndrome. This study investigated the intracompartmental pressure changes in anterolateral compartment of the leg during and immediately after anterolateral bridge plating of tibial fractures. Intracompartmental pressures were measured before and during plate application, just after the completion of fixation, and immediately and 4-5 min after the tourniquet release in 22 isolated closed comminuted tibial fractures. Baseline anterolateral compartment pressures were higher than those on the uninjured side (9.3 vs 27.8 mmHg). Pressures were 69.5, 57.4, 65.8, and 56.8 mmHg, respectively, for the other measurements times. None of the patients received prophylactic fasciotomy, and none developed clinical compartment syndrome. We found that anterolateral compartmental pressures were higher than pressures on the uninjured side in all patients. Although there is a considerable increase in intracompartmental pressures during and immediately after anterolateral percutaneous bridge plating of comminuted tibial fractures, intraoperative prophylactic fasciotomy is not routinely needed. One should monitor the patients on the first postoperative day for signs of compartment syndrome. Fasciotomy decisions should be based on both clinical symptoms and serial intracompartmental pressure measurements rather than a single measurement.

Acute Lower Leg Compartment Syndrome: A Rare Complication following CABG.

Compartment syndrome of lower legs following coronary artery bypass grafting is a rare complication which results from a combination of local and systemic factors. Early recognition is vital for good outcome. The case discussed describes this rare complication of CABG resulting in long term disability.

Are Orthopaedic Residents Competent at Performing Basic Nonoperative Procedures in an Unsupervised Setting? A "Pop Quiz" of Casting, Knee Arthrocentesis, and Pressure Checks for Compartment Syndrome.

Many patient care procedures are routinely performed by orthopaedic residents while not directly supervised by attending physicians. However, resident competence to perform these procedures is often presumed and not confirmed by objective measures. The purpose of this study was to formally evaluate 3 basic pediatric orthopaedic procedures commonly performed without attending supervision. All orthopaedic residents (n=20) were asked to complete 3 procedures (placement and removal of a short arm cast, aspiration of a knee joint, and compartment pressure checks of a leg) under direct attending supervision. Attending faculty developed a checklist for each procedure, listing the appropriate steps required and criteria with which to assess the final results. Scores were calculated, including means and SDs. Change in score by postgraduate year level was determined by simple linear regression. The mean score for short arm cast application and removal was 6.2 of a total possible score of 8, with an average 1.1 increase in score per year of training (P<0.001). Uneven cast padding and lack of full thumb motion were the most common reasons for losing points. Knee joint aspiration had an average score of 6.2 of 7, with an average increase in score of 0.3 per year of training (P=0.046). Lack of equipment preparation and not donning gloves in a sterile manner were the most common reasons for losing points. Measure of leg compartment pressures had an average score of 9.7 of 12, with an average increase in score of 0.5 per increase in year of training (P=0.087). Injecting an inappropriate amount of fluid and not recording measurements were the most common reasons for losing points. The ability of a resident to appropriately perform certain procedures without direct supervision improves with advancing level of training. The most junior residents might not appropriately be placing short arm casts, aspirating knee joints, or checking compartment pressures of the leg. Level II—Diagnostic.