Case Report

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

Atraumatic painless compartment syndrome

Abstract

Acute compartment syndrome is a time-sensitive diagnosis and surgical emergency because it poses a threat to life and the limbs. It is defined by Matsen et al (Surg Gynecol Obstet. 1978;147(6):943-949) as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.” The most common cause of compartment syndrome is traumatic injury. A variety of other conditions such as vascular injuries, Bleeding disorders, thrombosis, fasciitis, Gas gangrene, rhabdomyolysis, prolonged limb compression, cellulitis, and nephrot- ic syndrome may also cause compartment syndrome. Patients who are elderly, have preexisting nerve damage, or have psychopathology may have an atypical presentation. This case highlights the first report of a 75-year-old woman who developed painless bilateral compart- ment syndrome in the absence of traumatic injury.

Acute compartment syndrome is a time-sensitive diagnosis and surgical emergency because it poses a threat to life and the limbs [1]. It is defined by Matsen et al [2] as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.” The most common cause of compartment syndrome is traumatic injury [1]. A variety of other conditions such as vascular injuries, bleeding disorders, thrombosis, fasciitis, gas gangrene, rhabdomyolysis, prolonged limb compression, cellulitis, and Nephrotic syndrome may also cause compartment syndrome [1,3-6]. Clinical presentation can occur in a stepwise fashion that includes a spectrum of pain out of proportion to examination with progression to paralysis [7]. Patients who are elderly, have preexisting nerve damage, or have psychopathology may have an atypical presentation [8]. Emergency physicians should consider compartment syndrome in patients presenting to the emergency department with preceding trauma or the aforementioned underlying conditions and limb edema. Delays in diagnosis can result in amputation, disability, or death [1].

A 75-year-old woman was found at home by emergency medical services personnel in a kneeling position. Her feet had been feeling numb and stiff intermittently for weeks. She knelt down between her bed and dresser and was in that position for more than 4 hours and was unable to arise. The patient had a normal mental status, and there was no trauma or injury associated with the patient’s inability to arise. In the emergency department, both her legs were swollen and she was unsure for how long. She denied pain in her extremities. Her medical history included coronary artery disease, pulmonary embo- lism, dyslipidemia, Abdominal aortic aneurysm, and sciatica.

On physical examination, the patient had Swollen legs bilaterally with lividity of her feet. Her right lower extremity (RLE) revealed minimal feeling with pinching and light touch up to the knee. Her RLE

strength was 2/5 in her toes, ankle dorsiflexion, and plantar flexion and hip flexion. Her RLE knee flexion was 3/5, and she was unable to lift her right leg. Her RLE had a 2 + dorsalis pedis and posterior tibia pulse, and her foot was warm and well perfused. Her Left lower extremity revealed tense anterior, lateral, and posterior compart- ments. She had a 1 + dorsalis pedis and posterior tibia pulse that was faint compared with the right. She had no sensation to light touch or pinching up to the left knee. She was unable to lift her left leg or move her left knee. She could barely twitch her toes, and her motor function at the ankle was 1/5.

Laboratory studies revealed the following: blood urea nitrogen, 39 mg/dL; creatinine, 1.8 mg/dL; lactic acid, 7.9 mEq/L; and troponin,

35.2 ng/mL. Hepatic panel showed alanine aminotransferase of 170 U/ L and aspartate aminotransferase of 699 U/L. Urine analysis was positive for nitrites, large Leukocyte esterase, more than 900 white blood cells, and 4 + bacteria. Her Creatine phosphokinase was 40,517 U/L. Results from chest x-ray, pelvis x-ray, and head computed tomography were normal.

The intensive care unit was consulted, and an magnetic resonance imaging of the lumbar spine and pelvis were ordered. The lumbar spine showed degenerative disk disease, and the pelvis demonstrated nonspecific edematous legs. Compartment Pressure measurements performed by orthopedics in both legs in all compartments ranged between 25 and 65 mm Hg, and the diagnosis of compartment syndrome was made. The patient was taken immediately to the operating room and underwent bilateral lower leg fasciotomies (Figs. 1 and 2). She was given intravenous fluids, ceftriaxone intravenous for her urinary tract infection, and a bicarbonate drip

Fig. 1. Lateral RLE fasciotomy.

0735-6757/$ – see front matter (C) 2013

Fig. 2. Medial left lower extremity fasciotomy.

for rhabdomyolysis. During her hospital course, she developed ischemia of the left upper extremity because of arterial emboli. The patient developed acute renal failure secondary to severe rhabdomy- olysis and septic shock. She continued to decompensate and was made comfort care only and died 2 days after admission.

Compartment syndrome is typically seen after traumatic injury, but other conditions can cause this, as well [1,3-5]. Rapid diagnosis increases the possibility of treatment success, and failure to do so can lead to morbidity and mortality [1]. Typical symptoms described in the literature by Tiwari et al [3] are pain out of proportion to the associated injury, tense, swollen compartments, pain on passive stretching of the muscle, and sensory loss. It has been seen in other cases that compartment syndrome can be asymptomatic; however, those cases had preceding trauma or surgery [8,9]. The typical symptoms were brought in to question as well by Elliot and Johnstone [1] citing multiple articles questioning the effectiveness of typical compartment syndrome symptoms in identifying all cases of compartment syndrome. Our case is noteworthy because there have been no previously reported cases of painless bilateral compartment syndrome in a patient without trauma or recent surgery. When compartment syndrome is a possible diagnosis

and pain is not present, compartment pressure testing must be done to rule out the diagnosis [1-3,8].

Compartment syndrome can present without injury or pain, especially in elderly patients with comorbidities. Emergency physi- cians should consider this in their differential diagnosis in patients presenting with Leg swelling and neurovascular changes.

Scott Blanchard DO

Emergency Department Akron General Medical Center

Akron, OH, USA

Gregory D. Griffin Emergency Department Research Akron General Medical Center

Akron, OH, USA

Erin L. Simon DO

Emergency Department Akron General Medical Center

Akron, OH, USA E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.08.008

References

1. Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003;85(5):625-32.
2. Matsen FA, Krugmire RB. Compartmental syndromes. Surg Gynecol Obstet 1978;147(6):943-9.
3. Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg 2002;89(4):397-412.
4. Gopal V, Burns FE. Cellulitis and compartment syndrome due to Plesiomonas shigelloides: a case report. Mil Med 1991;156(1):43.
5. Huber FX, Eckstein HH, Allenberg JR. Bilateral tibial compartment syndrome with crush symptoms after cannabis abuse. Chirurg 1997;68(8):829-31.
6. Kim J, Zelken J, Sacks JM. CASE REPORT Spontaneous forearm compartment syndrome in a boy with hemophilia A: a therapeutic dilemma. Eplasty 2013;13:e16.
7. Towater LJ, Heron S. Foot compartment syndrome: a rare presentation to the emergency department. J Emerg Med 2013;44(2):e235-8.
8. Badhe S, Baiju D, Elliot R, Rowles J, Calthorpe D. The ‘silent’ compartment syndrome.

   Injury 2009;40(2):220-2.

   Wright JG, Bogoch ER, Hastings DE. The ‘occult’ compartment syndrome. J Trauma 1989;29(1):133-4.