Atraumatic idiopathic compartment syndrome requiring emergent fasciotomy
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A 42-year-old man with no past medical history and prescribed no medications presented to the ED with complaints of pain and swelling in his left lower leg during the last 48 hours.
The patient noticed the pain while walking to work the day prior but denied any trauma or injury to the leg. The pain did not resolve with rest. He stated the pain and swelling were progressively worsening, and he was now having difficulty ambulating, prompting him to come to the ED. On initial ED evaluation, the patient’s distal left lower extremity was moderately edematous compared with the contralateral side. Compartments were firm but compressible, and he was tender to palpation over the posterior lower leg. There was no pain with passive stretching of the great toe, but the patient endorsed pain with passive dorsiflexion of the ankle. The patient was neurovascularly intact distally, and complete secondary exam was negative for other orthopedic injuries.
Further workup included Dopplers, radiographs and a CT scan of the left lower extremity (Figure 1). Doppler ultrasound showed no evidence of a deep vein thrombosis. Radiographs demonstrated soft tissue swelling with no acute fractures or dislocations, and CT demonstrated a crescentic hyperdense collection along the medial gastrocnemius muscle in the left lower leg consistent with a hematoma measuring 10 cm anterior-posteriorly by 4 cm transversely by 20 cm craniocaudally. While the exam was abnormal, there was no concern for acute compartment syndrome at that time, and the patient was admitted to observation with compartment checks. The patient’s clinical picture remained stable during the following 12 hours, and he denied any worsening pain or swelling. Sixteen hours after initial consult, the patient was noted to have an interval increase in swelling and tension of the skin over the posterior lower leg when compared with the exam 4 hours prior. He was now endorsing paresthesia in the distribution of the tibial nerve, and worsening pain with passive dorsiflexion and plantarflexion of the ankle. He was otherwise neurovascularly intact distally.
Source: Benjamin Fielder, BS; Danielle H. Markus, MD; William H. Neal, MD; Nirmal Tejwani, MD
What are the next best steps in management of this patient?
See answer below.
Emergent fasciotomy
Given the worsening clinical picture, the patient was taken to the OR for compartment pressure testing and fasciotomy.
Surgical technique
Compartment pressure testing was performed in the OR using the arterial line transducer technique. Pressures were noted to be elevated primarily in the superficial posterior compartment with a delta of –8 mmHg relative to diastolic blood pressure (absolute compartment pressure 86 mmHg), and the deep posterior compartment with a delta of 7 mmHg (absolute compartment pressure 71 mmHg; Figures 2a and 2b). Anterior and lateral compartments were measured to be delta 50 mmHg.
Fasciotomies of all four compartments were immediately performed using a two-incision approach starting with a 20-cm incision along the posterior aspect of the medial tibia. Approximately 300 mL of hematoma was evacuated from the superficial compartment (Figure 3) with minimal amounts of necrosis noted superficially on the medial head of the gastrocnemius. The remainder of the gastrocnemius, as well as the posterior deep compartment after incision of the soleus bridge, appeared healthy and contractile, with no apparent source of arterial or obvious venous bleeding noted. After the superficial and deep posterior compartment release, the anterior and lateral compartments were noted to be soft and compressible. An incision measuring about 8 cm long was taken over the anterolateral compartment through the skin, subcutaneous tissue and fascia. The fascia of both the anterior and lateral compartments were released in prophylactic manner. Muscles in these compartments were noted to be viable and contractile. The lateral incision was closed. The medial incision was approximated using the Roman sandal vessel loop technique (Figure 4). A vacuum-assisted closure device was then applied for dressings.
Postoperative rehabilitation
The hematology service was consulted to determine if a coagulopathy or underlying disorder could have contributed; however, the resulting workup was negative. Vascular surgery performed a CT angiogram with arterial and venous phase without an apparent source of the bleeding.
Four days later, the patient was taken back to the OR for irrigation and debridement with definitive closure. He was allowed to weight-bear immediately postoperatively. At 1-month follow-up, the patient had no residual symptoms and the incision had healed appropriately.
Discussion
Compartment syndrome is a surgical emergency as delay in treatment can result in increased likelihood of adverse outcomes, such as higher rates of morbidity and mortality. While trauma is the most common cause of atraumatic compartment syndrome with an associated fracture in 69% of patients, a variety of atraumatic etiologies have been identified in the literature, including prolonged immobilization secondary to substance abuse, loss of consciousness or operative procedure; long-standing uncontrolled diabetes; use of anticoagulation medication; or an undiagnosed bleeding disorder. The average time from symptom onset to diagnosis of atraumatic compartment syndrome in patients without a fracture is approximately 2 days, similar to what was seen in the current presentation. The wide variance in patient population and injury patterns complicates diagnostic algorithms, as the clinician must maintain a high degree of suspicion even in those without fracture or high-energy mechanism. When compartment syndrome is due to atraumatic causes, clinicians often have a lower suspicion of index and, therefore, patients may be subject to longer times before receiving fasciotomy.
Calf strains are a common injury in athletes, typically presenting with the acute onset of focal calf pain and ecchymosis after injury. While typically treated conservatively, there have been a small number of cases published in the literature regarding a traumatic gastrocnemius rupture leading to atraumatic compartment syndrome in athletes. However, even more rare, cases have been reported related to a hematoma formation in setting of atraumatic rupture of gastrocnemius or soleus muscle in nonathletes leading to atraumatic compartment syndrome. Yan K Sit, MBBS(HK), FHKAM, FHKCOS, and colleagues describe a 55-year-old man with calf pain after chasing a bus, noted to have a gastrocnemius tear leading to atraumatic compartment syndrome. Similarly, Conor N. O’Neill, MD, and colleagues describe a 62-year-old man who was diagnosed with atraumatic compartment syndrome after a short track race, in which a soleus muscle tear resulted in 400 mL to 500 mL of hematoma. Li Tao, MD, and colleagues published the case of a 47-year-old man who was diagnosed with atraumatic compartment syndrome secondary to a gastrocnemius tear after stepping down from a truck bed. Notably, however, is that these described patients “felt a pop” despite the atraumatic mechanism. In comparison, the current case is unusual in its lack of pertinent risk factors or a known inciting injury (a “pop”).
It is commonly taught to diagnose compartment syndrome with the six P’s: pain, pallor, paresthesia, paralysis, pulselessness and poikilothermia. However, these diagnostic criteria have been called into question in a growing number of studies. Todd Ulmer, MD, has demonstrated that the sensitivity of these symptoms can be as low as 13% to 19%. However, when present, it can have a specificity up to 98%. Similarly, in the current presentation, the patient had no pain with passive stretch of his big toe, despite having pathologically high pressure in both the superior and deep compartments.
Key points:
- Trauma does not always precipitate compartment syndrome.
- Compartment syndrome should still be considered even without any host risk factors (ie, coagulopathies, on anticoagulation, immobilization).
- Even if clinical suspicion is low, patients with any compartment syndrome symptoms should either be admitted for observation or given extremely strict return precautions.
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- For more information:
- Andrew S. Bi, MD; Benjamin Fielder, BS; Danielle H. Markus, MD; William H. Neal, MD; and Nirmal Tejwani, MD, can be reached at the department of orthopedic surgery at NYU Langone Orthopedic Hospital in New York. Markus’s email: danielle.markus@nyulangone.org.
- Edited by Andrew Bi, MD, and Pooja Prabhakar, MD. Bi is a chief resident in the department of orthopedic surgery at NYU Langone. He will pursue a fellowship in sports medicine at Rush University Medical center following residency completion. Prabhakar is a chief resident in the department of orthopaedic surgery at the University of Washington. She will pursue a fellowship in foot and ankle surgery at Baylor University Medical Center following residency completion. For more information on submitting Orthopedics Today Grand Rounds cases, please email orthopedics@healio.com.
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