The Case: 55-year-old woman presented to the ED with two days of worsening bilateral leg pain, stiffness, and swelling. She first noticed a change two nights prior when she woke up to use the restroom and found she had some difficulty moving her legs. She noticed increased difficulty walking since that period. She denied any trauma, IVDU, or anticoagulant use. Prior to the onset of her symptoms, she routinely walked two to three miles each day.
Her initial exam demonstrated bilateral lower extremities swelling from the calves to the ankles, equal in size, with prominent superficial veins. She had palpable PT/DP, popliteal, and femoral pulses bilaterally. Both calves were tender, without overlying skin changes, without pain with passive stretch, and with sensation intact to light touch. She was afebrile, and well-appearing with BP 134/76, HR 95, RR 17, SpO2 98%. Plain radiographs were unremarkable and Doppler US revealed no DVT in either side. Labs demonstrated a CK of 21,489, a uric acid of 9.3, K of 3.4, Cr 1.1, AST 535, ALT 110, LDH 563, lactate 4.9, and clear urine. TSH was normal.
Fluids were started and the patient was admitted for rhabdomyolysis. Overnight, the patient developed more significant pain in the left leg that worsened with passive stretch. Orthopedics was consulted for concern for compartment syndrome and she was taken to the OR for fasciotomy of the anterior and lateral compartments of the left leg. Fasciotomy was not deemed necessary on the right but the patient was observed in the SICU with frequent compartment checks. No definitive etiology was determined for the compartment syndrome and the patient was ultimately discharged home in good condition.
Why it matters:
Compartment syndrome’s pathophysiology involves an increased pressure within a limited space that compromises the circulation and function within that space. The circulation of blood from high-pressure arteries to low pressure veins is dependent on a pressure differential between these vessels; as that gradient diminishes, the rates of delivery of oxygenated arterial blood and drainage of deoxygenated venous blood decreases. Tissue edema builds and ultimately leads to ischemia and irreversible necrosis. Clinical symptoms typically involve the 6 P’s: pain, paresthesia, pulseless, pallor, paralysis, and poikilothermia.
Diagnosing compartment syndrome can be very difficult. In fact, a recent study demonstrated the incidence of fasciotomy varied from 2 to 24%, which highlights just how variable surgical indications are for this diagnosis.1 Severe pain, and particularly pain with passive stretch of muscles, is often the earliest finding.2 This case highlights the importance of maintaining a high degree of suspicion, even in the absence of a clear etiology.
Fractures are the most common cause of acute compartment syndrome, accounting for about 69–75% of cases.1 Other etiologies include vascular (hemorrhage, reperfusion, hemophilia), soft-tissue injury (crush, burn), and iatrogenic (vascular puncture if anti-coagulated, casts).2 And yet, in this case, no obvious cause was found.
Other instances of compartment syndrome without an identifiable cause have been reported.3,4 Interestingly, there have been a number of case reports relating limb position to compartment syndrome (i.e. after prolonged surgical lithotomy position or bilateral peroneal compartment syndrome after horse riding).4 Given that our patient did first notice her symptoms in bed, it is possible that the etiology of her symptoms may have been positional.
Nonetheless, a high index of suspicion, early diagnosis, and a multidisciplinary approach can avoid a potentially devastating outcome.
Written by:
Alex Pezeshki, MD – PGY 4 | Cook County Health
Twitter: @PezeshkiMD
Reviewed by:
Scott Sherman, MD
Associate Program Director
Emergency Department
Cook County Hospital
References:
Via AG, Oliva F, Spoliti M, Maffulli N. Acute compartment syndrome. Muscles Ligaments Tendons J. 2015;5(1):18–22. Published 2015 Mar 27.
Tintinalli, Judith E.,, et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. Eighth edition. New York: McGraw-Hill Education, 2016.
Mahdi H, Gough S, Gill KK, Mahon B. Acute spontaneous compartment syndrome in recent onset type 1 diabetes. Emerg Med J. 2007;24(7):507–508. doi:10.1136/emj.2007.046425
Khan T, Lee GH, Alvand A, Mahaluxmivala JS. Spontaneous bilateral compartment syndrome of the legs: A case report and review of the literature. Int J Surg Case Rep. ;3(6):209–211. doi:10.1016/j.ijscr.2012.02.003