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Lateral compartment syndrome of the lower extremity in a recreational athlete: a case report
American Journal of Emergency Medicine (2008) 26, 973.e1–973.e2
www.elsevier.com/locate/ajem
Case Report Lateral compartment syndrome of the lower extremity in a recreational athlete: a case report
Abstract There are a limited number of reported cases of acuteonset isolated lateral compartment syndrome. We report a case of a 28-year-old recreational athlete who was erroneously diagnosed as having a muscle strain of his right lower extremity and discharged home. The patient over the course of the next day developed increasing leg pain and returned to the same emergency department where measurement of the peroneal compartment was 122 mm Hg. The patient had an emergent fasciotomy of the peroneal compartment of the right leg. The remainder of his hospital course was unremarkable. Although not commonly encountered, lateral compartment syndrome is important to consider in all patients who present with increasing pain out of proportion to injury and a tense swollen compartment after physical activity. A 28-year-old white man, while playing recreational softball, felt and heard something “pop” in his right leg. The patient was taken to an urgent care facility and was diagnosed as having a “simple muscle strain” and discharged on pain medication, crutches, and ace-wrap for comfort with follow-up instructions with his primary care physician if the need arises. The patient was also told to elevate his leg “above the heart” while lying supine to ameliorate his pain. Despite these modalities, the patient was taken to an emergency department the next day because of paresthesias radiating to the dorsum of his right foot and worsening pain in his right leg. On physical examination, the patient was noted to have tense swelling in the lateral compartment of his right leg with extreme pain to passive stretch of the peroneal muscles. The patient did not have any pain on passive stretch in any of the other compartments of his leg or foot. Pulses were normal and radiographs of the right leg and foot were negative for any fractures or dislocations. Measurement of the peroneal compartment was 122 mm Hg. The anterior, deep posterior, and superficial posterior compartments were all within normal limits. The patient was taken immediately to the operating room for emergent fasciotomy of the peroneal 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
compartment of the right leg using one standard lateral incision. The wound was left open and tensioned lightly with surgical bands. A sterile dressing was then placed on top of the wound. The patient was taken back to the operating room 2 days later for delayed primary closure of the wound, upon which viable contractile muscle of the peroneal compartment was noted. No skin grafting was needed. The patient otherwise had an unremarkable course and was discharged home the following day. The patient had a normal examination with no limp and no pain 1 month postoperatively. There are a limited number of reported cases of lateral compartment syndrome (LCS). Several case reports have included recreational athletes with increasing foot pain after a game following inversion ankle injuries [1] and in a soccer player after sustaining a peroneus longus tendon avulsion injury [2]. A review of the literature shows that LCS can commonly be misdiagnosed as muscle strain or contusion because LCS is uncommon. Increasing pain and paresthesias with decreased motion should increase suspicion for LCS [2]. In addition, LCS might present similarly to anterior compartment syndrome [3]. Acute compartment syndrome can also be superimposed on chronic compartment syndrome; this should be suspected if the chronic compartment syndrome pain does not resolve with cessation of activity as it had in the past [4]. Diagnosis of compartment syndrome can be made based on clinical symptoms and confirmed with pressure measurements. Signs and symptoms of compartment syndrome include pain out of proportion to the injury, pain, and weakness on passive motion, paresthesias, or hypoesthesia of nerves contained in involved compartments; and tense fascia enveloping the involved compartment [5]. An important aspect of management of acute compartment syndrome is the early diagnosis with appropriate therapy. Diagnosis is commonly made by history and physical examination. All of the above-reported cases had increasing pain with a progressive decrease in peroneal nerve sensation of the foot and leg. It is important to measure compartment pressures; however, the amount of pressure elevation and the condition necessary for elevation to diagnose compartment syndrome are not standardized [6]. Positioning the limb at the level of the heart facilitates venous drainage. If the limb is positioned higher as was initially performed in this case, a reduction in the
973.e2
Case Report
arteriovenous gradient may decrease perfusion pressure and contribute to further harm. Intraoperative findings during the lateral compartment fasciotomies typically showed ischemia [1], peroneus longus and/or brevis necrosis [1,6], or necrotic peroneus longus avulsed with no twitch to electrical stimulation [2]. An understanding of the cellular events that can cause compartment syndrome is important in the treatment of this condition. As tissue pressure increases and persists, irreversible cellular damage ensues. With severe oxygen deprivation, cellular degeneration occurs and organelles begin to release sodium, potassium, calcium, and myoglobin. Histamine is also released. When released into muscle, this potent inflammatory mediator causes progressive cellular swelling and tissue pressure elevation [7]. As local interstitial tissue pressure nears the diastolic blood pressure, a critical pressure is reached, which causes impairment to microvasculature flow [8]. If left untreated, compartment syndrome results in postischemic scarring and contracture. Lateral compartment syndrome is a rare diagnosis but should be considered in a patient with increasing pain out of proportion to injury, a tense swollen compartment, and decreasing passive motion of the leg and foot. Early diagnosis is important. This can be accomplished by physical examination with compartment pressure measurements as adjunct. Prompt surgical decompression is important for an improved outcome. Alysha J. Taxter BS Wright State University Boonshoft School of Medicine Dayton, OH 45409, USA
Emmanuel K. Konstantakos MD Donald W. Ames MD Department of Orthopaedic Surgery Sports Medicine, and Rehabilitation Wright State University Boonshoft School of Medicine Dayton, OH 45409, USA E-mail address: [email protected] doi:10.1016/j.ajem.2008.02.020
References [1] Ebenezer S, Dust W. Missed acute isolated peroneal compartment syndrome. CJEM 2002;4(5):355-8. [2] Davies J. Peroneal compartment syndrome secondary to rupture of the peroneus longus. A case report. J Bone Joint Surg Am 1979;61:783-4. [3] Edwards P. Peroneal compartment syndrome. Report of a case. J Bone Joint Surg Br 1969;51-B:123-5. [4] Goldfarb S, Kaeding C. Bilateral acute-on-chronic exertional lateral compartment syndrome of the leg: a case report and review of the literature. Clin J Sport Med: Off J Can Acad Sport Med 1997;7(1):59-61 [discussion 62]. [5] Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg 2007;73(12): 1199-209. [6] Goodman M. Isolated lateral-compartment syndrome. Report of a case. J Bone Joint Surg Am 1980;62:834. [7] Clanton TL, Klawitter PF. Adaptive responses of skeletal muscle to intermittent hypoxia: the known and the unknown. J Appl Physiol 2001;90:2476-87. [8] Ouellette EA. Compartment syndromes in obtunded patients. Hand Clin 1998;14:431-50.
www.elsevier.com/locate/ajem
Case Report Lateral compartment syndrome of the lower extremity in a recreational athlete: a case report
Abstract There are a limited number of reported cases of acuteonset isolated lateral compartment syndrome. We report a case of a 28-year-old recreational athlete who was erroneously diagnosed as having a muscle strain of his right lower extremity and discharged home. The patient over the course of the next day developed increasing leg pain and returned to the same emergency department where measurement of the peroneal compartment was 122 mm Hg. The patient had an emergent fasciotomy of the peroneal compartment of the right leg. The remainder of his hospital course was unremarkable. Although not commonly encountered, lateral compartment syndrome is important to consider in all patients who present with increasing pain out of proportion to injury and a tense swollen compartment after physical activity. A 28-year-old white man, while playing recreational softball, felt and heard something “pop” in his right leg. The patient was taken to an urgent care facility and was diagnosed as having a “simple muscle strain” and discharged on pain medication, crutches, and ace-wrap for comfort with follow-up instructions with his primary care physician if the need arises. The patient was also told to elevate his leg “above the heart” while lying supine to ameliorate his pain. Despite these modalities, the patient was taken to an emergency department the next day because of paresthesias radiating to the dorsum of his right foot and worsening pain in his right leg. On physical examination, the patient was noted to have tense swelling in the lateral compartment of his right leg with extreme pain to passive stretch of the peroneal muscles. The patient did not have any pain on passive stretch in any of the other compartments of his leg or foot. Pulses were normal and radiographs of the right leg and foot were negative for any fractures or dislocations. Measurement of the peroneal compartment was 122 mm Hg. The anterior, deep posterior, and superficial posterior compartments were all within normal limits. The patient was taken immediately to the operating room for emergent fasciotomy of the peroneal 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
compartment of the right leg using one standard lateral incision. The wound was left open and tensioned lightly with surgical bands. A sterile dressing was then placed on top of the wound. The patient was taken back to the operating room 2 days later for delayed primary closure of the wound, upon which viable contractile muscle of the peroneal compartment was noted. No skin grafting was needed. The patient otherwise had an unremarkable course and was discharged home the following day. The patient had a normal examination with no limp and no pain 1 month postoperatively. There are a limited number of reported cases of lateral compartment syndrome (LCS). Several case reports have included recreational athletes with increasing foot pain after a game following inversion ankle injuries [1] and in a soccer player after sustaining a peroneus longus tendon avulsion injury [2]. A review of the literature shows that LCS can commonly be misdiagnosed as muscle strain or contusion because LCS is uncommon. Increasing pain and paresthesias with decreased motion should increase suspicion for LCS [2]. In addition, LCS might present similarly to anterior compartment syndrome [3]. Acute compartment syndrome can also be superimposed on chronic compartment syndrome; this should be suspected if the chronic compartment syndrome pain does not resolve with cessation of activity as it had in the past [4]. Diagnosis of compartment syndrome can be made based on clinical symptoms and confirmed with pressure measurements. Signs and symptoms of compartment syndrome include pain out of proportion to the injury, pain, and weakness on passive motion, paresthesias, or hypoesthesia of nerves contained in involved compartments; and tense fascia enveloping the involved compartment [5]. An important aspect of management of acute compartment syndrome is the early diagnosis with appropriate therapy. Diagnosis is commonly made by history and physical examination. All of the above-reported cases had increasing pain with a progressive decrease in peroneal nerve sensation of the foot and leg. It is important to measure compartment pressures; however, the amount of pressure elevation and the condition necessary for elevation to diagnose compartment syndrome are not standardized [6]. Positioning the limb at the level of the heart facilitates venous drainage. If the limb is positioned higher as was initially performed in this case, a reduction in the
973.e2
Case Report
arteriovenous gradient may decrease perfusion pressure and contribute to further harm. Intraoperative findings during the lateral compartment fasciotomies typically showed ischemia [1], peroneus longus and/or brevis necrosis [1,6], or necrotic peroneus longus avulsed with no twitch to electrical stimulation [2]. An understanding of the cellular events that can cause compartment syndrome is important in the treatment of this condition. As tissue pressure increases and persists, irreversible cellular damage ensues. With severe oxygen deprivation, cellular degeneration occurs and organelles begin to release sodium, potassium, calcium, and myoglobin. Histamine is also released. When released into muscle, this potent inflammatory mediator causes progressive cellular swelling and tissue pressure elevation [7]. As local interstitial tissue pressure nears the diastolic blood pressure, a critical pressure is reached, which causes impairment to microvasculature flow [8]. If left untreated, compartment syndrome results in postischemic scarring and contracture. Lateral compartment syndrome is a rare diagnosis but should be considered in a patient with increasing pain out of proportion to injury, a tense swollen compartment, and decreasing passive motion of the leg and foot. Early diagnosis is important. This can be accomplished by physical examination with compartment pressure measurements as adjunct. Prompt surgical decompression is important for an improved outcome. Alysha J. Taxter BS Wright State University Boonshoft School of Medicine Dayton, OH 45409, USA
Emmanuel K. Konstantakos MD Donald W. Ames MD Department of Orthopaedic Surgery Sports Medicine, and Rehabilitation Wright State University Boonshoft School of Medicine Dayton, OH 45409, USA E-mail address: [email protected] doi:10.1016/j.ajem.2008.02.020
References [1] Ebenezer S, Dust W. Missed acute isolated peroneal compartment syndrome. CJEM 2002;4(5):355-8. [2] Davies J. Peroneal compartment syndrome secondary to rupture of the peroneus longus. A case report. J Bone Joint Surg Am 1979;61:783-4. [3] Edwards P. Peroneal compartment syndrome. Report of a case. J Bone Joint Surg Br 1969;51-B:123-5. [4] Goldfarb S, Kaeding C. Bilateral acute-on-chronic exertional lateral compartment syndrome of the leg: a case report and review of the literature. Clin J Sport Med: Off J Can Acad Sport Med 1997;7(1):59-61 [discussion 62]. [5] Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg 2007;73(12): 1199-209. [6] Goodman M. Isolated lateral-compartment syndrome. Report of a case. J Bone Joint Surg Am 1980;62:834. [7] Clanton TL, Klawitter PF. Adaptive responses of skeletal muscle to intermittent hypoxia: the known and the unknown. J Appl Physiol 2001;90:2476-87. [8] Ouellette EA. Compartment syndromes in obtunded patients. Hand Clin 1998;14:431-50.