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Delayed Diagnosis of Nontraumatic Acute Compartment Syndrome in an Adolescent Athlete

Alexander, Eben IV DO; Weppner, Justin DO

Author Information
American Journal of Physical Medicine & Rehabilitation: August 2021 - Volume 100 - Issue 8 - p e106-e108
doi: 10.1097/PHM.0000000000001662

BRIEF HISTORY AND PHYSICAL EXAMINATION

 A 15-yr-old adolescent boy with no significant medical history presented with 4 days of left lower limb swelling and pain. He was playing football 4 days prior when he reported cutting to juke an opponent and felt a popping sensation in his left knee. He noted immediate onset of throbbing pain in the front and lateral aspect of his leg distal to the knee, but no trauma was reported at the time of the injury. The patient kept playing and cutting in the game despite the pain. The patient did not report any further trauma. After the game, he experienced pain with difficulty ambulating, which necessitated further evaluation. On postinjury day 1, the patient was evaluated in an emergency department with pain at the anterolateral aspect of his left leg distal to the knee associated with weakness. The patient was diagnosed with a muscle strain, prescribed a nonsteroidal anti-inflammatory medication, and provided with crutches. On postinjury day 2, the patient was evaluated by an athletic trainer with concern for cellulitis and was referred to the emergency department for further evaluation. The patient was assessed in the emergency department a second time and was diagnosed with cellulitis and a muscle strain. Treatment at that time included cephalexin, rest, ice, and elevation in addition to nonsteroidal anti-inflammatory medications. No diagnostic studies were performed during either emergency department visits. The patient failed to respond to the previous treatment. On postinjury day 4, the patient presented to establish care with the author of the article reporting the presence of pain, burning, and swelling in the anterolateral aspect of his leg distal to the knee accompanied by numbness and tingling in the dorsum of his foot. He was ambulating using crutches with 9/10 pain and inability to bear weight on his left leg. His temperature was 98.6°F, heart rate was 92 beats per minute, blood pressure was 145/70 mm Hg, respiratory rate was 22 breaths per minute, and oxygen saturation was 98% on room air. The patient denied swelling around the left knee joint or patella but reported catching and popping. No left knee give way weakness was appreciated. The patient did not have any signs or symptoms of cellulitis.

Swelling was identified in the anterior and lateral leg compartments below the knee, but no swelling or erythema around the knee joint. Calf circumference was not measured. No joint line tenderness was appreciated at the knee; however, tenderness was noted on palpation over the anterior and lateral compartments of the leg below the knee. Full passive range of motion at the left knee was present, but there was absent dorsiflexion and limited inversion at the left ankle. Left lower limb strength was full except for 0/5 foot dorsiflexion, 2/5 plantar flexion, inversion, and eversion. Manual muscle testing was not limited by pain. A negative Lachman and posterior drawer were noted on orthopedic special testing. He had an equal amount of mild valgus laxity bilaterally, but no varus laxity was noted. There was diminished sensation to fine touch at the distal aspect of the third metatarsal and absent sensation over the anterior aspect of the ankle joint line. Sensation to fine touch over the medial malleolus and lateral calcaneus was intact. A long hypoechoic structure was noted on point-of-care ultrasound consistent with a hematoma that did not compress the common fibular nerve.

In summary, this is a 15-yr-old adolescent boy who sustained a nontraumatic injury to his left lower limb and presented with 4 days of progressive severe pain over the anterior and lateral compartments of the leg below the knee, numbness and tingling in his dorsal foot, and profound weakness with ankle plantar flexion and dorsiflexion.

This study conforms to all American Journal of Physical Medicine and Rehabilitation Resident and Fellow Section case reports guidelines and reports the required information accordingly (see Supplemental Checklist, Supplemental Digital Content 1, http://links.lww.com/PHM/B185).

DIFFERENTIAL DIAGNOSIS

  1. Compartment syndrome
  2. Common fibular neuropathy
  3. Torn fibular muscle complex
  4. Torn tibialis anterior
  5. Hematoma

Compartment syndrome was the leading differential diagnosis because of the numbness, tingling, weakness, swelling, tenderness of the anterolateral compartments, and absent sensation over the anterior aspect of the ankle joint. Common fibular neuropathy was next on the differential diagnosis because of the pattern of numbness and weakness. A fibular or tibial plateau fracture could have stretched or severed the fibular nerve. A torn muscle would explain the foot drop and swelling appreciated on examination; however, it would not explain the absence of sensation over the proximal dorsum of his foot. A long hypoechoic structure was noted on point-of-care ultrasound, which was likely representative of a hematoma; however, this too would not explain all of his symptoms (Fig. 1).

FIGURE 1
FIGURE 1:
Point-of-care ultrasound revealing lateral compartment hematoma.

DIAGNOSTIC RESULTS

No laboratory examination of blood was ordered initially as there was no perceived benefit of blood testing in an otherwise healthy 15-yr-old adolescent boy with a sports-related injury. A point-of-care ultrasound showed a hypoechoic region in the center of the lateral compartment 1 cm wide and spanning roughly 20 cm superior-inferior. No noticeable joint swelling or suprapatellar effusion was noted reducing the probability of intra-articular pathology. An x-ray showed a normal tibia and fibula with no evidence of fracture. A stat magnetic resonance imaging was ordered to look for possible late sequelae of compartment syndrome and rule out other etiologies. Magnetic resonance imaging of the left lower limb revealed “probable rupture of the proximal tendon of the peroneus longus with significant edema and enlargement of the muscle. The muscle could be at risk for compartment syndrome (Fig. 2).”

FIGURE 2
FIGURE 2:
T2-weighted coronal magnetic resonance imaging of the patient’s lower limbs showing increased signal over the left fibular muscles.

There was discussion to obtain compartment pressures; however, we perceived that it would not change management so late after the onset of an alleged compartment syndrome.

DIAGNOSIS AND DISCUSSION OF MANAGEMENT AND OUTCOME

Orthopedic surgery was consulted immediately after magnetic resonance imaging given the potential need for surgical intervention. Orthopedics evaluated the patient and decided to perform a left lower limb fasciotomy. Acute compartment syndrome is a surgical condition that must be diagnosed and treated promptly to prevent complications. Time is critically important to ensure that ischemic damage is avoided or minimized and delayed diagnosis may lead to necrotic tissue and muscle. A superior to inferior fasciotomy in the anterior and lateral compartments was performed. The surgeon noted the fibular nerve to be undisturbed, the anterior compartment muscle bellies appeared normal, and the lateral compartment muscle bellies had a significant amount of hematoma present. The peroneus longus muscle belly was dusky but did not appear necrotic. An ankle brace was prescribed at discharge from the hospital.

After surgery, the patient underwent 4 wks of physical therapy 3 times a week. The patient returned to his previous level of function 2 mos after surgery. During the 10-mo follow-up via teleconference, the patient did note pain on his foot’s plantar surface, which may be unrelated to his previous injury and did not limit his athletic performance.

This case exemplifies an unusual precipitating event leading to compartment syndrome. No matter how many healthcare providers a patient has been to, it is critical to be methodical and think critically to reach the correct diagnosis. Overall, fracture is the most common cause of acute compartment syndrome in children and adolescents, responsible for 85% of cases.1 The most common cause of acute compartment syndrome, specifically in the lower limb, is fracture of the tibial diaphysis. This accounts for 36% of presentations.2 Fracture is followed by blunt soft-tissue injury (i.e., crush injuries), which accounts for 13% of presentations.1 Other etiologies include injection injury, penetrating trauma, constrictive dressings, casts, thermal burns, infection, bleeding disorders, arterial injury, reperfusion of ischemic limbs, and extravasation of drugs.3 Although arterial injury is listed under other etiologies, most literature discusses trauma from an external source contributed to arterial injury per literature review.2,3

This case is also remarkable for this patient’s recovery despite delayed intervention. A study by Sheridan et al.4 of 44 individuals with 66 cases of acute compartment syndrome showed that fasciotomy done more than 12 hrs after onset of the compartment syndrome was associated with only 8% of patients regaining normal function. Even among those who had surgery within 12 hours, only 68% of them recovered normal function. Normal function was defined as no motor or sensory impairment, and assessing functional status using sensory or even motor impairment may be a poor surrogate to evaluate functional status. It is exceptionally remarkable that not only was this patient able to become functionally independent, but he was able to go back to competing at varsity level athletics.

REFERENCES

1. Grottkau BE, Epps HR, Di Scala C: Compartment syndrome in children and adolescents. J Pediatr Surg 2005;40:678–82
2. Shadgan B, Menon M, Sanders D, et al.: Current thinking about acute compartment syndrome of the lower extremity. Can J Surg 2010;53:329–34
3. Donaldson J, Haddad B, Khan WS: The pathophysiology, diagnosis and current management of acute compartment syndrome. Open Orthop J 2014;8:185–93
4. Sheridan GW, Matsen FA 3rd: Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am 1976;58:112–5
Keywords:

Compartment Syndrome; Fasciotomy; Sports Medicine; Ultrasound

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