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Undiagnosed compartment syndrome following anterior tibialis muscle hernia repair
Injury Extra (2007) 38, 59—60
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CASE REPORT
Undiagnosed compartment syndrome following anterior tibialis muscle hernia repair Derfel P. Williams *, Ali I. Hassan Orthopaedic Department, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston PR2 9HT, UK Accepted 3 July 2006
Introduction Muscle herniation is a relatively common condition, the majority of which occur in the leg. Although treatment is not required in most cases, incorrect management of this condition can result in serious consequences. It is therefore essential to understand the potential complications, and to ensure that the correct surgical procedure is performed when surgery is contemplated.
Case report A 25-year old man presented to the orthopaedic department with complaints of a painful swelling to his left shin following a reported fall a few months earlier. Subsequent review of hospital records however revealed that the swelling had been present for at least 5 years. At that time he was asymptomatic, and another surgeon discharged him following investigation. At his latest consultation, clinical examination confirmed a swelling along the lateral border of the tibia consistent with a tibialis anterior muscle hernia. The diagnosis was discussed and he was * Corresponding author. Tel.: +44 7941617728. E-mail address: [email protected] (D.P. Williams).
advised that surgery would not be recommended on cosmetic grounds. He was however experiencing significant pain and restriction of activities as a result of the hernia, and requested surgical intervention to deal with this. The risks of surgery were discussed, and he agreed to proceed with direct repair of the muscle hernia as a daycase. A longitudinal incision was made to the skin and subcutaneous tissue to expose the hernia. The extent of herniation at surgery was found to be greater than anticipated from clinical examination. Although requiring a little muscle excision, the defect was successfully closed, eliminating the herniation. Postoperatively the leg was placed in a light wool and crepe support, elevated, and nursing staff advised to monitor distal neurovascular status. He was advised to mobilise non-weight bearing for 4 weeks to protect the repair. Later that evening his pain had not been adequately controlled for discharge, and he was therefore admitted for pain control. During this admission he was seen by two on-call SHOs regarding his pain. Both documented normal neurovascular status, and advised changes to his analgesia. The following day, he was also seen by the pain nurse who advised further alterations to his analgesia. His pain was eventually brought under control and he was discharged home with outpatient follow up in 2 weeks.
1572-3461 # 2006 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2006.07.034
60 At the 2-week clinic review the wound had healed well with no evidence of infection or hernia recurrence. The patient reported no specific problems, and he was advised to continue non-weight bearing. By the 4-week review, the patient had noticed an inability to dorsiflex the foot together with altered sensation to the 1st web space. Examination confirmed a foot drop and decreased sensation in the deep peroneal nerve distribution. Urgent nerve conduction studies were performed which demonstrated no activity in the anterior compartment muscle group consistent with compartment syndrome. Peroneal nerve sensory activity was however retained. He is currently mobilising with a foot drop splint, and there are no immediate plans for further surgery.
Discussion The anterior tibial compartment is one of the commonest sites affected by muscle herniation. This usually occurs along the lateral border of the tibia at the fascial insertion. Trauma can cause rupture of the fascia allowing muscle to herniate through the defect. It is also seen as a result of regular vigorous exercise. This leads to muscle hypertrophy and increased compartmental pressures, which subjects the fascia to chronic stress with eventual hernia formation.3,4,9 Although diagnosis is relatively easy, treatment requires careful consideration. Many patients presenting with herniation will experience very little significant symptoms, and will be mainly concerned about the cosmetic appearance. Asymptomatic herniation requires no treatment apart from patient reassurance. In those experiencing significant pain and disability, however, further intervention may be warranted. Conservative management by means of an elasticated support may benefit some patients and should be considered as a first option.9 Failure of conservative management necessitates consideration of the surgical options. Several techniques have been described including direct closure,1,2,5,9 fascial grafts,8 mesh repair,6,7 and longitudinal fasciotomy.5 Although direct repair of the defect may seem a straightforward option, the possible consequences can be devastating for the patient. Reduction of the herniated muscle, and direct closure will result in a smaller and tighter compartment. Postoperative bleeding and oedema will also further exacerbate
D.P. Williams, A.I. Hassan any increase in compartmental pressure. This can therefore potentially develop into a full-blown anterior compartment syndrome.1,2,5,9 Even prompt recognition, and urgent fasciotomy can result in long-term disability due to the advanced muscle necrosis that rapidly occurs. In addition, this case highlights the importance of considering and recognising compartment syndrome in postoperative patients. Compartment syndrome is more commonly seen following trauma, but must not be forgotten as a possible complication of elective surgery. Any procedure on or near a fascial compartment can result in swelling or bleeding, which may increase compartmental pressures. As this case highlights, this may follow relatively minor surgery. Neurovascular status cannot be relied on for diagnosis, and a high index of suspicion is required in all cases. Pain out of proportion to the degree of trauma was the only finding in this case, and this should have suggested the diagnosis. In view of the risk and consequences of compartment syndrome, direct repair should not be considered in the surgical management of muscle herniation. We agree with previous advice5 that the most appropriate and simplest intervention to deal with the symptomatic hernia would be a longitudinal fasciotomy.
References 1. Almdahl SM, Due J, Samdal FA. Compartment syndrome with muscle necrosis following repair of hernia of tibialis anterior. Case report. Acta Chir Scand 1987;153:11—2. 2. Browne HS. Ischemic necrosis of muscle (acute anterior compartment syndrome) following repair of anterior compartment muscle hernias. R I Med J 1968;51(10):620—1. 3. Harrington AC, Mellette Jr JR. Hernias of the anterior tibialis muscle: case report and review of the literature. J Am Acad Dermatol 1990;22(1):123—4. 4. Lane JE, Woody CM, Lesher JL. Tibialis anterior muscle herniation. Dermatol Surg 2002;28(7):641—2. 5. Minaci A, Rorabeck CH. Compartment syndrome as a complication of repair of a hernia of the tibialis anterior. J Bone Joint Surg A 1986;68(9):1444—5. 6. Richards H, Thomas R, Upadhyay SS. Polypropylene mesh repair of iatrogenic thigh hernias. Injury 1998;29(6):478. 7. Siliprandi L, Martini G, Chiarelli A, Mazzoleni F. Surgical repair of an anterior tibialis muscle hernia with Mersilene mesh. Plast Reconstr Surg 1993;91(1):154—7. 8. Simon HE, Sacchet HA. Muscle hernias of the leg. Am J Surg 1945;67:87. 9. Wolfort FG, Mogelvang L, Filtzer HS. Anterior tibial compartment syndrome following muscle hernia repair. Arch Surg 1973;106:97—9.
www.elsevier.com/locate/inext
CASE REPORT
Undiagnosed compartment syndrome following anterior tibialis muscle hernia repair Derfel P. Williams *, Ali I. Hassan Orthopaedic Department, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Fulwood, Preston PR2 9HT, UK Accepted 3 July 2006
Introduction Muscle herniation is a relatively common condition, the majority of which occur in the leg. Although treatment is not required in most cases, incorrect management of this condition can result in serious consequences. It is therefore essential to understand the potential complications, and to ensure that the correct surgical procedure is performed when surgery is contemplated.
Case report A 25-year old man presented to the orthopaedic department with complaints of a painful swelling to his left shin following a reported fall a few months earlier. Subsequent review of hospital records however revealed that the swelling had been present for at least 5 years. At that time he was asymptomatic, and another surgeon discharged him following investigation. At his latest consultation, clinical examination confirmed a swelling along the lateral border of the tibia consistent with a tibialis anterior muscle hernia. The diagnosis was discussed and he was * Corresponding author. Tel.: +44 7941617728. E-mail address: [email protected] (D.P. Williams).
advised that surgery would not be recommended on cosmetic grounds. He was however experiencing significant pain and restriction of activities as a result of the hernia, and requested surgical intervention to deal with this. The risks of surgery were discussed, and he agreed to proceed with direct repair of the muscle hernia as a daycase. A longitudinal incision was made to the skin and subcutaneous tissue to expose the hernia. The extent of herniation at surgery was found to be greater than anticipated from clinical examination. Although requiring a little muscle excision, the defect was successfully closed, eliminating the herniation. Postoperatively the leg was placed in a light wool and crepe support, elevated, and nursing staff advised to monitor distal neurovascular status. He was advised to mobilise non-weight bearing for 4 weeks to protect the repair. Later that evening his pain had not been adequately controlled for discharge, and he was therefore admitted for pain control. During this admission he was seen by two on-call SHOs regarding his pain. Both documented normal neurovascular status, and advised changes to his analgesia. The following day, he was also seen by the pain nurse who advised further alterations to his analgesia. His pain was eventually brought under control and he was discharged home with outpatient follow up in 2 weeks.
1572-3461 # 2006 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2006.07.034
60 At the 2-week clinic review the wound had healed well with no evidence of infection or hernia recurrence. The patient reported no specific problems, and he was advised to continue non-weight bearing. By the 4-week review, the patient had noticed an inability to dorsiflex the foot together with altered sensation to the 1st web space. Examination confirmed a foot drop and decreased sensation in the deep peroneal nerve distribution. Urgent nerve conduction studies were performed which demonstrated no activity in the anterior compartment muscle group consistent with compartment syndrome. Peroneal nerve sensory activity was however retained. He is currently mobilising with a foot drop splint, and there are no immediate plans for further surgery.
Discussion The anterior tibial compartment is one of the commonest sites affected by muscle herniation. This usually occurs along the lateral border of the tibia at the fascial insertion. Trauma can cause rupture of the fascia allowing muscle to herniate through the defect. It is also seen as a result of regular vigorous exercise. This leads to muscle hypertrophy and increased compartmental pressures, which subjects the fascia to chronic stress with eventual hernia formation.3,4,9 Although diagnosis is relatively easy, treatment requires careful consideration. Many patients presenting with herniation will experience very little significant symptoms, and will be mainly concerned about the cosmetic appearance. Asymptomatic herniation requires no treatment apart from patient reassurance. In those experiencing significant pain and disability, however, further intervention may be warranted. Conservative management by means of an elasticated support may benefit some patients and should be considered as a first option.9 Failure of conservative management necessitates consideration of the surgical options. Several techniques have been described including direct closure,1,2,5,9 fascial grafts,8 mesh repair,6,7 and longitudinal fasciotomy.5 Although direct repair of the defect may seem a straightforward option, the possible consequences can be devastating for the patient. Reduction of the herniated muscle, and direct closure will result in a smaller and tighter compartment. Postoperative bleeding and oedema will also further exacerbate
D.P. Williams, A.I. Hassan any increase in compartmental pressure. This can therefore potentially develop into a full-blown anterior compartment syndrome.1,2,5,9 Even prompt recognition, and urgent fasciotomy can result in long-term disability due to the advanced muscle necrosis that rapidly occurs. In addition, this case highlights the importance of considering and recognising compartment syndrome in postoperative patients. Compartment syndrome is more commonly seen following trauma, but must not be forgotten as a possible complication of elective surgery. Any procedure on or near a fascial compartment can result in swelling or bleeding, which may increase compartmental pressures. As this case highlights, this may follow relatively minor surgery. Neurovascular status cannot be relied on for diagnosis, and a high index of suspicion is required in all cases. Pain out of proportion to the degree of trauma was the only finding in this case, and this should have suggested the diagnosis. In view of the risk and consequences of compartment syndrome, direct repair should not be considered in the surgical management of muscle herniation. We agree with previous advice5 that the most appropriate and simplest intervention to deal with the symptomatic hernia would be a longitudinal fasciotomy.
References 1. Almdahl SM, Due J, Samdal FA. Compartment syndrome with muscle necrosis following repair of hernia of tibialis anterior. Case report. Acta Chir Scand 1987;153:11—2. 2. Browne HS. Ischemic necrosis of muscle (acute anterior compartment syndrome) following repair of anterior compartment muscle hernias. R I Med J 1968;51(10):620—1. 3. Harrington AC, Mellette Jr JR. Hernias of the anterior tibialis muscle: case report and review of the literature. J Am Acad Dermatol 1990;22(1):123—4. 4. Lane JE, Woody CM, Lesher JL. Tibialis anterior muscle herniation. Dermatol Surg 2002;28(7):641—2. 5. Minaci A, Rorabeck CH. Compartment syndrome as a complication of repair of a hernia of the tibialis anterior. J Bone Joint Surg A 1986;68(9):1444—5. 6. Richards H, Thomas R, Upadhyay SS. Polypropylene mesh repair of iatrogenic thigh hernias. Injury 1998;29(6):478. 7. Siliprandi L, Martini G, Chiarelli A, Mazzoleni F. Surgical repair of an anterior tibialis muscle hernia with Mersilene mesh. Plast Reconstr Surg 1993;91(1):154—7. 8. Simon HE, Sacchet HA. Muscle hernias of the leg. Am J Surg 1945;67:87. 9. Wolfort FG, Mogelvang L, Filtzer HS. Anterior tibial compartment syndrome following muscle hernia repair. Arch Surg 1973;106:97—9.