Mabazza, Karen R.

BSN 3I

Compartment Syndrome of the Leg: Case Reports

Case 1
A 22-year-old man was hit by a car while riding his bicycle and
sustained fractures of the right distal radius and proximal humerus, as well
as a subtrochanteric fracture of the left femur. On physical examination, he
was alert and oriented. He had obvious deformity and pain around the distal
radius and proximal humerus. The left thigh was swollen, ecchymotic, painful
to palpation, and without any evidence of open wound. The pulses distal to
the thigh were normal bilaterally, as were results of motor and sensory
examination. The patient did not complain of any pain in the left leg, which
had normal range of motion and showed no signs of trauma. Radiographs of
the left thigh showed a large, unstable comminuted subtrochanteric femoral
fracture.
The fractures of the distal radius and proximal humerus were surgically
addressed first, with the patient on a regular operating room table. The
femoral fracture was then stabilized with an intramedullary hip screw (Smith
& Nephew, Memphis, Tenn). For this procedure, the patient was transferred
from the regular table onto a traction and orthopedic surgery operating table
(Chick, Versailles, Ohio) and placed in the hemilithotomy position with the
right leg elevated on a well-padded stirrup. The intramedullary nailing was
completed in 3 hours 15 minutes (total anesthesia, 10 hours), and in the
recovery room, his initial complaint was pain in the lower extremity that had
been elevated. Physical examination at that time documented that the leg
had become swollen and tense. This leg pain increased with palpation and
passive toe and ankle movement. As a secondary diagnostic criterion,
compartment pressures were measured with a Stryker 295-2 Quick Pressure
Monitor Set (Kalamazoo, Mich). The pressures ranged from 60 to 90 mm Hg
in each of the compartments.
The patient was returned to the operating room immediately for
fasciotomies to release all of the leg compartments.[12] Postoperatively, he
complained of paresthesias involving the plantar surface of the right foot.
These resolved within 10 days, and at 3 months, he started progressive
weight-bearing. At 6 months after the injury, the patient was without
complaint and had returned to his employment as a carpenter. At final
follow-up 31/2 years later, he had a normal gait, symmetric leg lengths,
painless ambulation, and a radiographically healed fracture. The right leg
fasciotomy wounds were healed, and the patient was without complaints.

Case 2
A 23-year-old man sustained an isolated right subtrochanteric femoral
fracture as an unrestrained driver in a motor vehicle accident. On physical
examination in the emergency room, he was alert, oriented, and without
complaints of injury to the left leg. Vascular and neurologic findings were
normal in both legs. The right thigh had no open wounds but was swollen
and painful. Radiographs showed that this fracture had a large area of
comminution with an unstable configuration.
The operative procedure, using a Zimmer intramedullary
reconstruction nail (Warsaw, Ind), done on a Jackson fracture table
(Orthopedic Systems Inc, Union City, Calif) with the right leg elevated in a
padded stirrup. The procedure lasted 3 hours 45 minutes. At the end of the
procedure, but before extubation, a "secondary survey" physical
examination was done. During this examination, the left, elevated leg was
found to be swollen and tense. A Stryker 295-2 Quick Pressure Monitor Set
was used to measure the compartment pressures that ranged between 50
and 80 mm Hg in all four compartments of the leg. The patient was then
transferred onto a regular operating room table, and all of the leg
compartments were released with fasciotomies. Postoperatively, the patient
had global paresthesias on the plantar and dorsal surfaces of the affected
foot to the area of the malleoli.
Three months later, the patient continued to have moderate pain in
the thigh and paresthesias in the foot. Radiographs at that time showed a
healing fracture, and progressive weight-bearing was started. Over the next
3 months, the thigh pain diminished, and he was able to return to work as a
brick mason; however, he continued to have a global lack of sensation on the
left foot from the malleoli distally.
 At final follow-up 2 years after the injury, radiographs showed a healed
fracture (Fig 2). The leg lengths were not symmetric, the right side being
shorter than the right by 2 cm. The paresthesias that began after surgery
had not resolved. His gait was not antalgic, but he reported moderate thigh
and foot pain when standing for 3 hours or more. The patient expressed
satisfaction with the surgery but did complain that his foot pain
compromised the number of hours he could work in a day.
REFERENCE: http://www.medscape.com/viewarticle/429552_2