Anatomy Msk · Year 1 · from Anatomy Msk
Case 2: Acute Compartment Syndrome of the Leg
Clinical Image
Source: Wikimedia Commons - Compartment Syndrome - CC BY-SA 3.0
Case Presentation
A 19-year-old man is admitted following closed reduction and casting of a right tibial shaft fracture sustained during a motorcycle accident. Eight hours after injury, he reports worsening pain in his right leg that is not controlled with IV morphine. He describes the pain as severe, constant, and burning, located throughout his lower leg. The nursing staff notes increasing analgesic requirements. Physical examination reveals a tense, swollen right leg. Pain is dramatically increased with passive extension of the toes (stretch of flexors in deep posterior compartment) and passive toe flexion (stretch of extensors in anterior compartment). The cast has been bivalved. Sensation is diminished over the first web space (deep peroneal nerve). Dorsalis pedis pulse is palpable. Intracompartmental pressure measurements reveal elevated pressures in all four compartments: anterior (55 mmHg), lateral (45 mmHg), deep posterior (52 mmHg), and superficial posterior (42 mmHg). Diastolic blood pressure is 80 mmHg, giving a delta pressure of 25-38 mmHg (abnormal <30). He is taken emergently to the operating room for four-compartment fasciotomy. At surgery, the muscles appear dusky but pink up after release. The fascia is left open and the wounds closed with skin grafting 5 days later.
Key Learning Points
- The leg has four compartments: anterior, lateral, superficial posterior, and deep posterior
- Compartment syndrome occurs when increased pressure compromises perfusion and tissue viability
- Pain out of proportion and pain with passive stretch are early findings; pulselessness is a late/ominous sign
- Pressure measurement: absolute >30 mmHg or delta pressure (diastolic BP - compartment pressure) <30 mmHg indicates fasciotomy
- Tibial fractures are the most common cause; delay in treatment leads to Volkmann-type contracture and rhabdomyolysis