543360
research-articleXXXX
FASXXX10.1177/1938640014543360Foot & Ankle SpecialistFoot & Ankle Specialist
vol. 8 / no. 1
Foot & Ankle Specialist
〈 Case Report 〉 Acute Compartment Syndrome After Medial Gastrocnemius Tear
Yan Kit Sit, MBBS (HK), FHKAM, FHKCOS, and Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS
Abstract: Acute compartment syndrome after medial gastrocnemius tear is very rare. It can involve the superficial posterior compartment alone or progress to involve all the 4 compartments of the lower legs. Those patients with high pain tolerance and minor trauma can lead to delayed presentation. Immediate fasciotomy is the treatment of choice.
Rupture of the gastrocnemius muscle is an uncommon injury, with most cases occurring in athletes and, typically, presenting with the acute onset of focal calf pain and ecchymosis after injury. Gastrocnemius ruptures are usually treated symptomatically with good results.2 We present a case of acute compartment syndrome of the lower leg complicated by medial gastrocnemius tear in a nonathlete.
Levels of Evidence: Therapeutic Level IV, Case Study
Case Report
Keywords: compartment syndrome; muscle tear; gastrocnemius
A
cute compartment syndromes usually occur as a complication of major trauma, for example, tibial fracture or severe blunt trauma, but can also be the result of noncontact musculotendinous strains or tears with rupture of small vessels and intracompartmental hemorrhage. These soft tissue insults may occur acutely or may develop out of a chronic exertional process.1 Other causes include overexertion and nontraumatic events such as acute rhabdomyolysis, druginduced myositis, and eosinophilic myositis.
“
numbness over the foot, and the passive motion of the toes and ankle was not so painful. The dorsalis pedis and posterior tibial pulses were not palpable but dopplable. Compartment pressures of the lower leg were measured. The pressures of the superficial posterior, deep posterior, lateral (peroneal) and anterior compartments were 100 mm Hg, 80 mm Hg, 80 mm Hg, and 50 mm Hg, respectively. Emergency operation of fasciotomy with the medial and lateral
A 55-year-old technician complained of Rupture of the gastrocnemius muscle sudden onset of right calf pain associated with a is an uncommon injury, with most cases “pop” after chasing a occurring in athletes.” bus. The calf pain and swelling progressively increased in the following hours, and he was admitted incisions was performed 19 hours after to our department through the the injury. Blood platelet count and emergency room 16 hours after the clotting profile was checked before the injury. He was sport inactive and has operation, and the results were within history of hypertension and atypical normal limit. Intraoperatively, all the 4 chest discomfort with mild coronary compartments were tense with the artery disease. He was initially put on muscles herniated through the incisions aspirin, but stopped by himself since 4 of the deep fascia. The muscles were months before this incident. Clinically, viable. There was complete tear of the his right calf was swollen, tense, and medial head of the gastrocnemius about tender. There was no paraesthesia or 15 cm below the knee joint. More than
DOI: 10.1177/1938640014543360. From the Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong SAR, China. Address correspondence to: Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS, Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)
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Figure 1. Intraoperative photos. (A) Tear (arrow) of the medial head of the gastrocnemius muscle was identified through the medial fasciotomy wound. (B) The bleeding artery was clamped by a haemostat.
100 mL of blood clot was found in the posterior compartment. A bleeding artery was found distal to the tear and between the gastrocnemius and the soleus (Figure 1). The bleeding artery was ligated. Delayed primary closure of the fasciotomy wounds was performed 5 days later and the muscles still looked viable. On 21 months of follow-up, he was all along asymptomatic without sequelae of compartment syndrome.
Discussion Acute exertional compartment syndromes of the lower leg can be isolated involvement or one that has progressed to involve all the 4 compartments.3-7 Differential diagnoses should include acute arterial occlusion, neuropraxia, cellulitis, osteomyelitis, stress fracture, tenosynovitis, deep vein thrombosis, shin sprints, and medial tibial stress syndrome.3 The cause of acute superficial posterior
compartment is hematoma formation with8,9 or without muscle tear.5,10 On the other hand, acute compartment syndrome associated with rupture of the medial head of gastrocnemius can involve the superficial posterior compartment alone8,11 or all the 4 compartments2,9,12 of the lower leg. The cause of excessive bleeding and blood clot formation in this case was believed to be due to the torn artery identified intraoperatively. It is interesting that the torn artery was distal to the muscle tear. It may be because of the underlying pathology of the artery that made it vulnerable to tear, for example, arteriosclerosis, as the patient has a long history of hypertension. Acute compartment syndrome, whether due to major trauma, minor trauma, or simple exertion, is primarily a clinical diagnosis.5 The characteristic presentation of compartment syndrome is pain out of proportion to the
perceptible injury, which is worsened by passive stretching of the involved muscles. In the initial stage when only the superficial posterior compartment is involved, the passive toe motion should not cause excessive pain and passive ankle dorsiflexion should be tested. Once the deep posterior compartment and the anterior compartment are involved, passive toe motion should be painful. Those patients with high pain tolerance may lead to a delay of diagnosis,5,9 as in this case. Another reason of the delay of the diagnosis in this case was due to the relatively minor trauma leading to the delay of seeking medical care by this patient. Acute compartment syndrome after muscle rupture, although rare, is a limb-threatening condition, which warrants emergency treatment. Immediate fasciotomy is mandatory and often results in full recovery.6 Overlooked, unrecognized, or surgically
Downloaded from fas.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 3, 2015
vol. 8 / no. 1
Foot & Ankle Specialist
untreated compartment syndrome can cause severe damage, including the loss of the extremity.5,9 Pai and Pai2 have demonstrated that release of superficial posterior compartment in children can relieve the pressure of other compartments. In this situation, decompressing the posterior compartment alone may decrease pressure in the anterior and lateral compartments and may avoid unnecessary fasciotomy of the anterior compartment, although intraoperative assessment, both before and after fasciotomy, will guide the surgeon’s degree of intervention.2 We are not sure whether this is applicable in an adult as another study showed that limited fasciotomy was initially effectively in lowering the compartment pressures but subsequently failed by clinical and objective assessment.5 Therefore, formal complete fasciotomy of all the 4 compartments of the lower leg was performed in this case and complete recovery resulted.
Conclusion Acute compartment syndrome after medial gastrocnemius tear is very rare. High degree of suspicion is needed for prompt diagnosis. Immediate fasciotomy is the treatment of choice.
References 1. Blacklidge DK, Kurek JB, Soto AD, Kissel CG. Acute exertional compartment syndrome of the medial foot. J Foot Ankle Surg. 1996;35:19-22. 2. Pai V, Pai V. Acute compartment syndrome after rupture of the medial head of gastrocnemius in a child. J Foot Ankle Surg. 2007;46:288-290. 3. Brodsky M, Bongiovanni MS. Bilateral lower leg acute exertional compartment syndrome. Orthopedics. 2000;23: 607-609. 4. Ebenezer S, Dust W. Missed acute isolated peroneal compartment syndrome. CJEM. 2002;4:355-358. 5. Fehlandt A Jr, Micheli L. Acute exertional anterior compartment syndrome in an adolescent female. Med Sci Sports Exerc. 1995;27:3-7.
6. Mubarak SJ, Owen CA, Garfin S, Hargens AR. Acute exertional superficial posterior compartment syndrome. Am J Sports Med. 1978;6:287-290. 7. Slabaugh M, Oldham J, Krause J. Acute isolated lateral leg compartment syndrome following a peroneus longus muscle tear. Orthopedics. 2008;31:272. 8. Allen MJ, Barnes MR. Unusual cause of acute superficial posterior compartment syndrome. Injury. 1992;23:202-203. 9. Thennavan AS, Funk L, Volans AP. Acute compartment syndrome after muscle rupture in a non-athlete. J Accid Emerg Med. 1999;16:377-378. 10. Stack C. Superficial posterior compartment syndrome of the leg with deep venous compromise. A case report. Clin Orthop Relat Res. 1987;220:233-236. 11. Russell GV Jr, Pearsall AW IV, Caylor MT, Nimityongskul P. Acute compartment syndrome after rupture of the medial head of the gastrocnemius muscle. South Med J. 2000;93:247-249. 12. Straehley D, Jones WW. Acute compartment syndrome (anterior, lateral and superficial posterior compartment) following tear of gastrocnemius muscle. A case report. Am J Sports Med. 1986;14:96-99.
Downloaded from fas.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 3, 2015
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research-articleXXXX
FASXXX10.1177/1938640014543360Foot & Ankle SpecialistFoot & Ankle Specialist
vol. 8 / no. 1
Foot & Ankle Specialist
〈 Case Report 〉 Acute Compartment Syndrome After Medial Gastrocnemius Tear
Yan Kit Sit, MBBS (HK), FHKAM, FHKCOS, and Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS
Abstract: Acute compartment syndrome after medial gastrocnemius tear is very rare. It can involve the superficial posterior compartment alone or progress to involve all the 4 compartments of the lower legs. Those patients with high pain tolerance and minor trauma can lead to delayed presentation. Immediate fasciotomy is the treatment of choice.
Rupture of the gastrocnemius muscle is an uncommon injury, with most cases occurring in athletes and, typically, presenting with the acute onset of focal calf pain and ecchymosis after injury. Gastrocnemius ruptures are usually treated symptomatically with good results.2 We present a case of acute compartment syndrome of the lower leg complicated by medial gastrocnemius tear in a nonathlete.
Levels of Evidence: Therapeutic Level IV, Case Study
Case Report
Keywords: compartment syndrome; muscle tear; gastrocnemius
A
cute compartment syndromes usually occur as a complication of major trauma, for example, tibial fracture or severe blunt trauma, but can also be the result of noncontact musculotendinous strains or tears with rupture of small vessels and intracompartmental hemorrhage. These soft tissue insults may occur acutely or may develop out of a chronic exertional process.1 Other causes include overexertion and nontraumatic events such as acute rhabdomyolysis, druginduced myositis, and eosinophilic myositis.
“
numbness over the foot, and the passive motion of the toes and ankle was not so painful. The dorsalis pedis and posterior tibial pulses were not palpable but dopplable. Compartment pressures of the lower leg were measured. The pressures of the superficial posterior, deep posterior, lateral (peroneal) and anterior compartments were 100 mm Hg, 80 mm Hg, 80 mm Hg, and 50 mm Hg, respectively. Emergency operation of fasciotomy with the medial and lateral
A 55-year-old technician complained of Rupture of the gastrocnemius muscle sudden onset of right calf pain associated with a is an uncommon injury, with most cases “pop” after chasing a occurring in athletes.” bus. The calf pain and swelling progressively increased in the following hours, and he was admitted incisions was performed 19 hours after to our department through the the injury. Blood platelet count and emergency room 16 hours after the clotting profile was checked before the injury. He was sport inactive and has operation, and the results were within history of hypertension and atypical normal limit. Intraoperatively, all the 4 chest discomfort with mild coronary compartments were tense with the artery disease. He was initially put on muscles herniated through the incisions aspirin, but stopped by himself since 4 of the deep fascia. The muscles were months before this incident. Clinically, viable. There was complete tear of the his right calf was swollen, tense, and medial head of the gastrocnemius about tender. There was no paraesthesia or 15 cm below the knee joint. More than
DOI: 10.1177/1938640014543360. From the Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong SAR, China. Address correspondence to: Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS, Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)
Downloaded from fas.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 3, 2015
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Figure 1. Intraoperative photos. (A) Tear (arrow) of the medial head of the gastrocnemius muscle was identified through the medial fasciotomy wound. (B) The bleeding artery was clamped by a haemostat.
100 mL of blood clot was found in the posterior compartment. A bleeding artery was found distal to the tear and between the gastrocnemius and the soleus (Figure 1). The bleeding artery was ligated. Delayed primary closure of the fasciotomy wounds was performed 5 days later and the muscles still looked viable. On 21 months of follow-up, he was all along asymptomatic without sequelae of compartment syndrome.
Discussion Acute exertional compartment syndromes of the lower leg can be isolated involvement or one that has progressed to involve all the 4 compartments.3-7 Differential diagnoses should include acute arterial occlusion, neuropraxia, cellulitis, osteomyelitis, stress fracture, tenosynovitis, deep vein thrombosis, shin sprints, and medial tibial stress syndrome.3 The cause of acute superficial posterior
compartment is hematoma formation with8,9 or without muscle tear.5,10 On the other hand, acute compartment syndrome associated with rupture of the medial head of gastrocnemius can involve the superficial posterior compartment alone8,11 or all the 4 compartments2,9,12 of the lower leg. The cause of excessive bleeding and blood clot formation in this case was believed to be due to the torn artery identified intraoperatively. It is interesting that the torn artery was distal to the muscle tear. It may be because of the underlying pathology of the artery that made it vulnerable to tear, for example, arteriosclerosis, as the patient has a long history of hypertension. Acute compartment syndrome, whether due to major trauma, minor trauma, or simple exertion, is primarily a clinical diagnosis.5 The characteristic presentation of compartment syndrome is pain out of proportion to the
perceptible injury, which is worsened by passive stretching of the involved muscles. In the initial stage when only the superficial posterior compartment is involved, the passive toe motion should not cause excessive pain and passive ankle dorsiflexion should be tested. Once the deep posterior compartment and the anterior compartment are involved, passive toe motion should be painful. Those patients with high pain tolerance may lead to a delay of diagnosis,5,9 as in this case. Another reason of the delay of the diagnosis in this case was due to the relatively minor trauma leading to the delay of seeking medical care by this patient. Acute compartment syndrome after muscle rupture, although rare, is a limb-threatening condition, which warrants emergency treatment. Immediate fasciotomy is mandatory and often results in full recovery.6 Overlooked, unrecognized, or surgically
Downloaded from fas.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 3, 2015
vol. 8 / no. 1
Foot & Ankle Specialist
untreated compartment syndrome can cause severe damage, including the loss of the extremity.5,9 Pai and Pai2 have demonstrated that release of superficial posterior compartment in children can relieve the pressure of other compartments. In this situation, decompressing the posterior compartment alone may decrease pressure in the anterior and lateral compartments and may avoid unnecessary fasciotomy of the anterior compartment, although intraoperative assessment, both before and after fasciotomy, will guide the surgeon’s degree of intervention.2 We are not sure whether this is applicable in an adult as another study showed that limited fasciotomy was initially effectively in lowering the compartment pressures but subsequently failed by clinical and objective assessment.5 Therefore, formal complete fasciotomy of all the 4 compartments of the lower leg was performed in this case and complete recovery resulted.
Conclusion Acute compartment syndrome after medial gastrocnemius tear is very rare. High degree of suspicion is needed for prompt diagnosis. Immediate fasciotomy is the treatment of choice.
References 1. Blacklidge DK, Kurek JB, Soto AD, Kissel CG. Acute exertional compartment syndrome of the medial foot. J Foot Ankle Surg. 1996;35:19-22. 2. Pai V, Pai V. Acute compartment syndrome after rupture of the medial head of gastrocnemius in a child. J Foot Ankle Surg. 2007;46:288-290. 3. Brodsky M, Bongiovanni MS. Bilateral lower leg acute exertional compartment syndrome. Orthopedics. 2000;23: 607-609. 4. Ebenezer S, Dust W. Missed acute isolated peroneal compartment syndrome. CJEM. 2002;4:355-358. 5. Fehlandt A Jr, Micheli L. Acute exertional anterior compartment syndrome in an adolescent female. Med Sci Sports Exerc. 1995;27:3-7.
6. Mubarak SJ, Owen CA, Garfin S, Hargens AR. Acute exertional superficial posterior compartment syndrome. Am J Sports Med. 1978;6:287-290. 7. Slabaugh M, Oldham J, Krause J. Acute isolated lateral leg compartment syndrome following a peroneus longus muscle tear. Orthopedics. 2008;31:272. 8. Allen MJ, Barnes MR. Unusual cause of acute superficial posterior compartment syndrome. Injury. 1992;23:202-203. 9. Thennavan AS, Funk L, Volans AP. Acute compartment syndrome after muscle rupture in a non-athlete. J Accid Emerg Med. 1999;16:377-378. 10. Stack C. Superficial posterior compartment syndrome of the leg with deep venous compromise. A case report. Clin Orthop Relat Res. 1987;220:233-236. 11. Russell GV Jr, Pearsall AW IV, Caylor MT, Nimityongskul P. Acute compartment syndrome after rupture of the medial head of the gastrocnemius muscle. South Med J. 2000;93:247-249. 12. Straehley D, Jones WW. Acute compartment syndrome (anterior, lateral and superficial posterior compartment) following tear of gastrocnemius muscle. A case report. Am J Sports Med. 1986;14:96-99.
Downloaded from fas.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 3, 2015
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