JAccid Emerg Med 1999;16:377-378 377

Acute compartment syndrome after muscle J Accid Emerg Med: first published as 10.1136/emj.16.5.377 on 1 September 1999. Downloaded from rupture in a non-athlete

A S Thennavan, L Funk, A P Volans

Abstract ination and progressive, direct wound closure. Acute compartment syndrome after mus- He was discharged from hospital after eight cle rupture, although rare, is a limb days, and proceeded to make a full recovery. threatening condition, which warrants emergency treatment. The case of acute Discussion compartment syndrome secondary to a Compartment syndrome is defined as the gastrocnemius muscle tear of the right elevation of interstitial pressure in closed lower leg, in a non-athlete is reported. To fascial compartment that results in microvas- our knowledge, this is the only description cular compromise. Compartment syndrome is of acute compartment syndrome due to a potentially serious complication of extremity muscle rupture in a non-athlete. trauma.' (J Accid Emerg Med 1999;16:377-378) Prolonged elevation of tissue pressure in a closed compartment results in myoneural Keywords: compartment syndrome; non-athlete; mus- hypoxia. Bleeding within the compartment or cle rupture oedema may cause this raised pressure. This in turn causes reduced blood flow through the compartment, which increases the hypoxia, Case report reduces cell function and increases the likeli- A 47 year old white male farmer walked into hood of further oedema. Tissue pressure can the accident and emergency (A&E) depart- rise sufficiently to reduce tissue perfusion ment complaining ofprogressive swelling in his below that required for tissue viability. right calf, mild pain, and cold right foot after a The characteristic presentation of compart- jump of about 3-4 feet off a tractor nine hours ment syndrome is pain out ofproportion to the earlier. He had not taken any analgesia for the perceptible injury, which is worsened by pain and he carried on with the routine farm passive stretching of the involved muscles.' work. He was otherwise fit and well. He was Late signs are paresis and parasthesia by which not on any medication. time permanent tissue damage is likely. The On examination, he had a tensely swollen diagnosis of compartment syndrome can be right calf, which was 6 cm greater in diameter difficult, especially where a low trauma injury than the left calf. He had surprisingly little pain occurs and the patient has a high pain when performing active or passive movements tolerance, as in this case. The diagnosis may be of the right ankle and foot. Simmond's test aided by the measuring of the relevant http://emj.bmj.com/ suggested intact calf musculature and tendo- compartment pressures. calcaneus. The dorsalis pedis pulsation was not Both experimental and clinical experience palpable but was detected with Doppler. The has demonstrated that normal pressure within posterior tibial pulsation was palpable but fee- the closed compartment is 0 mm Hg. This ble. Sensation was diminished in the distribu- pressure increases significantly in compart- tion of the sural nerve. ment syndrome. Fasciotomy is usually indi-

Lower leg compartment pressures were cated if the pressure raises above 40 to 45 mm on September 24, 2021 by guest. Protected copyright. measured in the A&E department, using Hg in a patient who has diastolic blood Whiteside's technique.' The following pres- pressure of 70 mm Hg and any signs or symp- sures were found: 70 mm Hg in the anterior toms of compartment syndrome.' McQueen compartment, 40 mm Hg in the lateral and Court-Brown recommend that decom- compartment, and 70 mm Hg in the posterior pression should be performed when the compartment. His blood pressure was 130/90 compartment pressure approaches to within mm Hg. 30 mm Hg ofthe diastolic.2 Other authors have Radiography did not demonstrate any bony quoted absolute figures ranging between 30 injuries. White cell count was raised at 13 x and 60 mm Hg.'3 A definite indication for fas- 109/1. Routine biochemistry and coagulation ciotomy is tissue pressure that equals or studies were normal. exceeds the diastolic pressure. It is generally Scarborough General The clinical diagnosis of advanced acute accepted that surgery is performed as soon as Hospital, Scarborough compartment syndrome was made. The pa- possible. A S Thennavan tient was taken to the theatre immediately for Compartment syndrome may be acute or L Funk fasciotomies. All three lower leg compartments A P Volans chronic in onset, depending on the aetiology. were decompressed through medial and lateral Acute compartment syndrome is usually a Correspondence to: incisions. The medial head of gastrocnemius result of direct trauma and may occur in Mr Funk, 39 Bottom o' th' was found to have ruptured at the musculo- athletes and non-athletes, depending on the Moor, Horwich, Lancs BL6 tendinous All the muscles were is the 6QF. junction. cause. Chronic compartment syndrome viable. The patient returned to theatre three result of repetitive indirect muscle trauma and Accepted 20 March 1999 times over the next week for the wound exam- occurs mainly in athletes. 378 Kotnis, Halstead, Hormbrey

Acute compartment syndrome may be a of the body of gastrocnemius has been

result of any trauma to the limb. The trauma is reported in athletes.7 8 This, however, is the J Accid Emerg Med: first published as 10.1136/emj.16.5.377 on 1 September 1999. Downloaded from usually a result of an open or closed fracture of first reported case of acute compartment the bones, or a crush injury to the limb. Other syndrome caused by a gastrocnemius muscle causes include haematoma, gun shot or stab rupture in a non-athlete. wounds, animal or insect bites, post-ischaemic swelling, vascular damage, electrical injuries, burns, prolonged tourniquet times, etc. Other Conclusion causes of compartment syndrome are genetic, Soft tissue injuries and muscle tears occur fre- iatrogenic, or acquired coagulopathies, infec- quently in athletes. Most injuries result from tion, nephrotic syndrome or any cause of direct trauma. Indirect trauma resulting in decreased tissue osmolarity and capillary per- muscle tears and ruptures can cause acute meability. compartment syndrome in athletes. It is also Chronic compartment syndrome is most important to keep in mind the possibility of typically an exercise induced condition charac- similar injuries in a non-athlete as well. More terised by a relative inadequacy of musculofas- research is needed to define optimal manage- cial compartment size producing chronic or ment patterns and potential strategies for recurring pain and/or disability. It is seen in injury prevention. athletes, who often have recurring leg pain that Conflict of interest: none. starts after they have been exercising for some Funding: none. time. There is no history oftrauma. The pain is 1 Mabee JR, Bostwick TL. Pathophysiology and mechanisms localised to the involved muscles or the entire of compartment syndrome. Orthopaedic Reviews 1993; 1 75- 80. compartment and the symptoms are very simi- 2 McQueen MM, Court-Brown CM. Compartment monitor- lar to acute compartment syndrome. The ing in tibial fractures-the pressure threshold for decom- pression. Jf Bone joint Surg Br 1995;78:99-104. symptoms often settle with rest, however if the 3 Blick SS, Brumback RJ, Poka A, et al. Compartment athlete returns to his sport after laying off, the syndrome in open tibial fractures. J Bone Joint Surg Am 1986;68: 1348-53. symptoms usually recur. The treatment of con- 4 Hargens AR, Akeson WH, Mubarak SJ, et al. Tissue fluid firmed chronic compartment syndrome is a pressures: from basic research tools to clinical applications. Jf Orthop Res 1989;7:902-9. surgical fasciotomy of the affected compart- 5 Matsen FA III, Winquist RA, Krugmire RB Jr. Diagnosis ments. and management of compartmental syndromes. J Bone Joint Surg Am 1980;62:286-9 1. Essentially, any cause of increased compart- 6 Mubarak SJ, Owen CA, Hargens AR, et al. Acute compart- ment pressure can result in a compartment ment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone joint Surg Am 1978;60: 1091-5. syndrome. Muscle rupture has been implicated 7 Mohanna PN, Haddad FS. Acute compartment syndrome in causing increased compartment pressures in following non-contact football injury. Br Jf Sports Med 1997;31:254-5. athletes after severe exercise. The diagnosis of 8 Best TM. Soft-tissue injuries and muscle tears. Clin Sports acute compartment syndrome due to rupture Med 1997;16(30):419-34.

Atraumatic bilateral Achilles tendon rupture: an http://emj.bmj.com/ association of systemic steroid treatment

R A Kotnis, J C Halstead, P J Hormbrey on September 24, 2021 by guest. Protected copyright.

Abstract care treatment two months previously, after A case ofbilateral Achilles tendon rupture which he had been started on oral pred- associated with steroid use is reported. nisolone. His respiratory symptoms were well This case illustrates the importance of controlled at the time of presentation. There taking a thorough drug history in cases of was no history of any tendon or joint pathology Accident and tendon rupture. In lower limb tendon rup- before the steroid treatment. Emergency ture all patients, especially those on Examination revealed a palpable gap in his Department, John steroids, should be warned of the in- left Achilles tendon 2 cm proximal to the inser- Radcliffe Hospital, creased risk of contralateral injury. tion on the calcaneum. A diagnosis of ruptured Oxford (JAccid Emerg Med 1999;16:378-379) R A Kotnis Achilles tendon was made and the patient was J C Halstead Keywords: Achilles tendon; steroid use placed in an equinus plaster of Paris below P J Hormbrey knee cast. The next day repair of the tendon Case report under local anaesthetic was performed utilising Correspondence to: an open technique; at surgery the tendon Dr Rohit A Kotnis, A 67 year old man presented to the accident Department ofAccident and and emergency department with sudden onset appeared degenerate. The equinus cast was Emergency, John Radcliffe of left sided calf pain that occurred while reapplied with a plan to change to the Hospital, Headington, crossing a road. He was unable to weight bear mid-equinus position in two weeks and then to Oxford OX3 3DU. on his left leg. This previously fit male had a Samson boot for mobilisation of the ankle Accepted 29 April 1999 developed severe pneumonia needing intensive within four weeks.