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Closed avulsion of the Tibialis Anterior: an unusual cause of compartment syndrome
Injury, Int. J. Care Injured 31 (2000) 738 – 739 www.elsevier.com/locate/injury
Case report
Closed avulsion of the Tibialis Anterior: an unusual cause of compartment syndrome B. Machani, B. Narayan *, H.B. Casserly Department of Orthopaedics, Warrington District General Hospital, Warrington WA5 1QG, UK Accepted 9 March 2000
Numerous causes have been described for acute compartment syndrome in the leg. We report an unusual injury caused by a conveyor belt at work, which led to a closed avulsion of the Tibialis Anterior from its origin and the consequent compartment syndrome. In addition to describing another cause for compartment syndrome, this report also highlights the need for admission and monitoring of all closed ‘soft-tissue’ injuries in the leg.
fasciotomy wounds were apposed with vascular silastic loops, and were skin-grafted by plastic surgeons 8 days after the injury. The graft sites healed over the next 2 weeks. The patient had some stiffness of the ankle and weakness of dorsiflexion but this improved with physiotherapy, and he regained Grade 4 power of ankle dorsiflexion after 4 months. He subsequently defaulted from the clinic.
1. Report
2. Discussion
A 35-year-old male was admitted for observation when he trapped his leg between a conveyor belt and a wall at work. He had associated abrasions over the medial aspect of the popliteal fossa and a puncture wound on the lateral aspect of his leg. Sensation and circulation were normal, and he had no bony injury. He developed increasing leg pain soon after admission, and a compartment syndrome was clinically suspected. He therefore underwent a double-incison four-compartment crural fasciotomy, as described by Mubarak and Hargens [1]. On opening the anterolateral compartment, the Tibialis Anterior was noted to be completely avulsed from its origin. It was found mostly avascular and rolled up on itself, in the lower half of the leg. The vascularity improved significantly on restoring the muscle towards its origin, and a minimal debridement was perfomed. The muscle was tacked back to its site of origin, and the wounds left open. Repeat debridement of the wounds was performed 48 h later, and some necrotic muscle was trimmed. The
Numerous causes have been described in the literature for compartment syndromes in the leg. Though most of these are related to fractures, other important causes include post-ischemic swelling, osteotomies and arterial injections. While reports of closed rupture of the Tibialis Anterior tendon, or the musculotendinous junction exist, a MEDLINE® search revealed only one similar case [2], which involved an avulsion of both the Tibialis Anterior and the peroneal muscles. The mode of injury described in that report is a direct trauma consequent to a road traffic accident, and the compartment syndrome occurred a day after the injury. The patient in this report trapped his leg between a moving conveyor belt and a wall, and the movement of the belt presumably sheared the muscle belly from its origin, resulting in this unusual injury pattern. Delay in exploration would have caused further necrosis of the muscle belly. A high index of suspicion is therefore needed when dealing with such closed injuries, and we emphasise the need for repeated clinical monitoring. Prompt exploration can be associated with a good outcome.
* Corresponding author. E-mail address: [email protected] (B. Narayan).
0020-1383/00/$ - see front matter © 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 0 9 5 - 4
B. Machani et al. / Injury, Int. J. Care Injured 31 (2000) 738–739
Presumably, the multiple levels of blood supply to the Tibialis Anterior through the anterior tibial and its recurrent branches [3] enabled the majority of the muscle belly to survive the injury. It is tempting to consider that the residual weakness in the Tibialis Anterior is mainly due to reattachment of the muscle belly to a more distal site of origin, and the consequent ‘overlengthening’ of the muscle. However, other significant causes such as a reduction in the muscle bulk consequent to the debridement, and poor post-traumatic revascularisation may also be contributory.
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739
References [1] Mubarak SJ, Hargens AR. Compartment syndromes and Volkmann’s contracture. In: Canale TS, editor. Saunders monographs in clinical orthopaedics, vol. 3, Philadelphia, 1981. Quoted by Azar FM and Pickering RM. ‘Traumatic Disorders’. Campbell’s operative orthopaedics, 9th ed., Mosby, 1998, pp. 1408 –1409 [2] Freundlich BD, Dashiff JE. Avulsion of Tibialis Anticus and Peronei Muscles resulting in acute anterior and lateral compartment syndrome. Journal of Trauma 1987;27:453 – 4. [3] Gabella G. Popliteal Artery in ‘Cardiovascular’. In: Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ, editors. Grays Anatomy, 38th ed. Edinburgh: Churchill Livingstone, 1995:1570 – 1.
Case report
Closed avulsion of the Tibialis Anterior: an unusual cause of compartment syndrome B. Machani, B. Narayan *, H.B. Casserly Department of Orthopaedics, Warrington District General Hospital, Warrington WA5 1QG, UK Accepted 9 March 2000
Numerous causes have been described for acute compartment syndrome in the leg. We report an unusual injury caused by a conveyor belt at work, which led to a closed avulsion of the Tibialis Anterior from its origin and the consequent compartment syndrome. In addition to describing another cause for compartment syndrome, this report also highlights the need for admission and monitoring of all closed ‘soft-tissue’ injuries in the leg.
fasciotomy wounds were apposed with vascular silastic loops, and were skin-grafted by plastic surgeons 8 days after the injury. The graft sites healed over the next 2 weeks. The patient had some stiffness of the ankle and weakness of dorsiflexion but this improved with physiotherapy, and he regained Grade 4 power of ankle dorsiflexion after 4 months. He subsequently defaulted from the clinic.
1. Report
2. Discussion
A 35-year-old male was admitted for observation when he trapped his leg between a conveyor belt and a wall at work. He had associated abrasions over the medial aspect of the popliteal fossa and a puncture wound on the lateral aspect of his leg. Sensation and circulation were normal, and he had no bony injury. He developed increasing leg pain soon after admission, and a compartment syndrome was clinically suspected. He therefore underwent a double-incison four-compartment crural fasciotomy, as described by Mubarak and Hargens [1]. On opening the anterolateral compartment, the Tibialis Anterior was noted to be completely avulsed from its origin. It was found mostly avascular and rolled up on itself, in the lower half of the leg. The vascularity improved significantly on restoring the muscle towards its origin, and a minimal debridement was perfomed. The muscle was tacked back to its site of origin, and the wounds left open. Repeat debridement of the wounds was performed 48 h later, and some necrotic muscle was trimmed. The
Numerous causes have been described in the literature for compartment syndromes in the leg. Though most of these are related to fractures, other important causes include post-ischemic swelling, osteotomies and arterial injections. While reports of closed rupture of the Tibialis Anterior tendon, or the musculotendinous junction exist, a MEDLINE® search revealed only one similar case [2], which involved an avulsion of both the Tibialis Anterior and the peroneal muscles. The mode of injury described in that report is a direct trauma consequent to a road traffic accident, and the compartment syndrome occurred a day after the injury. The patient in this report trapped his leg between a moving conveyor belt and a wall, and the movement of the belt presumably sheared the muscle belly from its origin, resulting in this unusual injury pattern. Delay in exploration would have caused further necrosis of the muscle belly. A high index of suspicion is therefore needed when dealing with such closed injuries, and we emphasise the need for repeated clinical monitoring. Prompt exploration can be associated with a good outcome.
* Corresponding author. E-mail address: [email protected] (B. Narayan).
0020-1383/00/$ - see front matter © 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 0 9 5 - 4
B. Machani et al. / Injury, Int. J. Care Injured 31 (2000) 738–739
Presumably, the multiple levels of blood supply to the Tibialis Anterior through the anterior tibial and its recurrent branches [3] enabled the majority of the muscle belly to survive the injury. It is tempting to consider that the residual weakness in the Tibialis Anterior is mainly due to reattachment of the muscle belly to a more distal site of origin, and the consequent ‘overlengthening’ of the muscle. However, other significant causes such as a reduction in the muscle bulk consequent to the debridement, and poor post-traumatic revascularisation may also be contributory.
.
739
References [1] Mubarak SJ, Hargens AR. Compartment syndromes and Volkmann’s contracture. In: Canale TS, editor. Saunders monographs in clinical orthopaedics, vol. 3, Philadelphia, 1981. Quoted by Azar FM and Pickering RM. ‘Traumatic Disorders’. Campbell’s operative orthopaedics, 9th ed., Mosby, 1998, pp. 1408 –1409 [2] Freundlich BD, Dashiff JE. Avulsion of Tibialis Anticus and Peronei Muscles resulting in acute anterior and lateral compartment syndrome. Journal of Trauma 1987;27:453 – 4. [3] Gabella G. Popliteal Artery in ‘Cardiovascular’. In: Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ, editors. Grays Anatomy, 38th ed. Edinburgh: Churchill Livingstone, 1995:1570 – 1.