Injury Extra 40 (2009) 68–69

Case report

Acute non-traumatic compartment syndrome of anterior compartment of leg;an unusual presentation: A case report

Ashish Paul *, Shalinder Sadiq, Jeewan S. Prakash

Department of Orthopaedics, Christian Medical College & Hospital, Ludhiana 141008, Punjab, India

A R T I C L E I N F O

Article history:

Accepted 19 November 2008

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1. Introduction

Acute compartment syndrome is a condition of elevatedpressure within a closed osteofascial compartment that reducescapillary blood perfusion to muscles and nerves below a levelnecessary for tissue/cellular viability.7,2 The clinical features arecontinuous severe pain, painful passive stretching of the involvedmuscles and diminished sensations.6

2. Case report

50-year-old male, a cottage industry owner, presented at 02:00complaining of feeling cold, shivering and with severe pain in rightleg. He had no prior history of leg pain. The previous morning hehad played football for the first time for 15 min when the outsidetemperature was about two degree celsius. He had no fall, twistingof leg/foot, or direct trauma to the leg. Throughout the day he hadperformed his routine activities without any discomfort or pain.Approximately 12 h later he started feeling cold. He was put under5 layers of blankets which did not help and the shivering persisted.Within an hour he developed pain in right leg and lower abdomen.He vomited twice and passed loose stools once.

Oral NSAID’S prescribed by a GP did not relieve his pain.Another GP gave an analgesic injection along with a tranquiliser. Asthe pain persisted he presented to the emergency services.

He was afebrile. Local examination revealed a swollen, wood-hard, tender, anterior compartment of the leg with dilatedsuperficial veins (Figs. 1 and 2). Passive dorsiflexion of the toesand ankle were painful. Extensor hallucis longus and extensordigitorum longus had grade 1/5 motor power and tibialis anterior

* Corresponding author. Tel.: +91 98 78 833343 (Mobile).

E-mail addresses: drashishpaul@google.com, drashishpaul@gmail.com (A. Paul).

1572-3461/$ – see front matter � 2008 Elsevier Ltd. All rights reserved.

doi:10.1016/j.injury.2008.11.025

grade 2/5. The dorsum of the foot had hypoesthesia. Dorsalis pedisand posterior tibial pulses were well palpable.

Baseline haematocrit and biochemistry values were withinnormal limits. The radiographs were normal.

The patient was immediately taken to theatre for decompres-sion. Fasciotomy by Mubarak’s single longitudinal lateral incisionwas done within 6 h of onset of leg pain.5 There was no free blood/clots and no oedema fluid in the compartment. The anteriorcompartment muscles bulged, were dark brown and did notcontract on pinching with tissue forceps but showed sluggishcontractility on electrical stimulation (Fig. 3).

The wound was dressed and intravenous pentoxyphylline andantibiotics were administered along with supportive therapy.

When the effect of spinal anaesthesia wore off after 3 h, thepatient had regained grade 3/5 motor power of EHL, EDL and tibialisanterior. After 12 h motor recovery was complete [grade 5/5]. Lateron split thickness skin graft was applied which had 100% uptake(Fig. 4).

A year later the patient was performing his routine activitieswithout any complaints in his right leg.

3. Discussion

The diagnosis of acute compartment syndrome requires a highdegree of clinical suspicion based on muscle and nerve ischaemia.8

Distal pulses are rarely obliterated yet perfusion may becompromised. Clinical and experimental evidences prove thatirreversible tissue damages can occur in a patient with palpablepulses. Ashton et al.1 advocate that the diagnosis must be madeessentially on clinical grounds and must be acted upon promptly ifserious and potentially irreversible injury to relevant compart-ment is to be avoided. Intramuscular pressure recordings assumesignificance in patients with chronic exercise induced anteriorcompartment leg pain in whom history and clinical signs areconsidered insufficient to establish a diagnosis of chronic anterior

Figs. 1 and 2. Swollen anterior compartment right leg.

Fig. 3. Showing anterior compartments under better illumination. Intra operatively

the muscles looked dark red.

Fig. 4. Showing skin graft well taken up.

A. Paul et al. / Injury Extra 40 (2009) 68–69 69

compartment syndrome.9 Webb and Grossling10 and McKee andJupiter4 also emphasise the importance of the history and clinicalfindings to arrive at a diagnosis.

In our literature search we came across a report of 20-year-oldman who developed acute anterior tibial compartment syndromeafter playing soccer for 5 min. The diagnosis was delayed for 18 hleading to delayed neuromuscular regeneration problems.11

In our patient the clinical diagnosis was confirmed on promptdecompressive fasciotomy, when dark brown uncontractilemuscles bulged out from within a relatively bloodless compart-ment, but showed remarkable motor recovery within 12 h offasciotomy.

A similar observation was made by Janbon et al.3 when a 40-year-old female was diagnosed with compartment syndromewhen she presented with a sensation of cold and pain in both feet.

4. Conclusion

Acute non-traumatic compartment syndrome patients usuallypresent with a history of exercise induced pain. However we sawan adult male with a history of unaccustomed exercise for 15 min,12 h prior to developing complaints and excessive shivering.Passive stretch pain of the involved compartment muscles waspositive and the compartment felt hard. Without wasting any time,we performed a fasciotomy. Our clinical judgment was vindicatedby the intraoperative findings and by a complete recovery postoperatively.

Exercise induced acute compartment syndrome presentingwith a sensation of cold, excessive shivering, vomiting and loosestools was an unusual combination.

References

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2. Botte MJ, Gilberman. Acute compartment syndrome of the forearm. Hand Clin1998;14(3):391–403.

3. Janbon C, Claustre J, Mary H, Simon L. An unusual compartment syndrome.Plebologie 1987;40(2):309–14.

4. McKee MD, Jupiter JB. Acute exercise-induced bilateral anterolateral leg com-partment syndrome in a healthy young man. Am J Orthop 1995;24(11):862–4.

5. Mubarek SJ, Owen CA. Double incision fasciotomy of the leg for decompressionin compartment syndromes. J Bone Joint Surg 1977;59A:184–7.

6. Mubarek SJ, Owen CA, Hargens AR. Acute compartment syndromes: diagnosisand treatment with the aid of the wick catheter. JBJS 1978;60A:1091–5.

7. Naidu SH, Heppenstall RB. Compartment syndrome of the forearm and hand.Hand Clin 1994;10(1):13–27.

8. Schnall SB, Holtom PD, Silva E. Compartment syndrome associated with infec-tion of the upper extremity. Clin Orthop 1994;306:128–31.

9. Styf J. Chronic exercise-induced pain in anterior aspect of lower leg: an over-view of diagnosis. Sports Med 1989;7(5):331–9.

10. Webb LX, Grossling S. Exertional compartment syndrome in a Marine grunt. MilMed 1992;157(3):154–5.

11. Willy C, Becker HP, Evers B, Gerngross H. Unusual development of acuteexertional compartment syndrome due to delayed diagnosis. A case report.Int J Sports Med 1996;17(6):458–61.