Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 261-263

Lower leg compartment syndrome detected by peripheral angiography


Department of Anaesthesia and Intensive Care, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India

Date of Submission24-Aug-2020
Date of Decision15-Oct-2020
Date of Acceptance17-Oct-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Sanjeev Kumar Singla
Department of Anaesthesia and Intensive Care, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_122_20

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  Abstract 


Compartment syndrome occurs when the pressure within a defined compartmental space increases past a critical pressure threshold jeopardizing the blood supply. Compartment syndrome can occur in any area of the body with closed compartments. The below-knee leg is the most likely compartment to develop acute compartment syndrome, followed by the forearm, thigh, and arm. Rapid diagnosis and treatment can be life or limb saving. Any delay in evaluating and treating patients with lower extremity compartment syndrome can be devastating for the patient. High suspicion is needed to diagnose the condition. The classic signs of compartment syndrome, the “6 P's,” can be deceiving. Advanced diagnostic techniques like peripheral angiography at the earliest can be lifesaving.

Keywords: Compartment syndrome, creatine phosphokinase, fasciotomy, foot


How to cite this article:
Singla SK. Lower leg compartment syndrome detected by peripheral angiography. Indian J Vasc Endovasc Surg 2021;8:261-3

How to cite this URL:
Singla SK. Lower leg compartment syndrome detected by peripheral angiography. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 26];8:261-3. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/261/320617




  Introduction Top


Compartment syndrome occurs when the pressure within a defined compartmental space increases past a critical pressure threshold, thereby decreasing the perfusion pressure to that compartment.[1] Compartment syndrome can occur in any area of the body with closed compartments. The below-knee leg is the most likely compartment to develop acute compartment syndrome, followed by the forearm, thigh, and arm.[2] Lower extremity compartment syndrome is not common without obvious signs and has the potential to cause devastating morbidity for patients. Rapid diagnosis and treatment can be life or limb saving. Paralysis, pulselessness, and paresthesias present late in the disease process, often after irreversible nerve and muscle damage, and should not routinely be part of the diagnostic criteria for acute compartment syndrome. We present the case of a middle-aged female who presented with pregangrenous changes in the foot without any obvious signs of compartment syndrome.


  Case Report Top


We present the case of a 40-year-old female patient with no comorbidities, who was referred to us with complaints of pain in the right foot below the malleolar level for 2-day duration associated with black discoloration of the entire foot for 7 h. There was no history of any trauma, infection, animal bites, or any risk factor for deep venous thrombosis. She was treated as a case of deep vein thrombosis outside and then referred to our center. All the routine investigations were within normal limits. Her creatinine kinase level was within normal limits. On clinical examination, the limb was warm, duskiness of entire right foot below the level of the ankle with impending gangrene. There were no signs of compartment syndrome on palpation. Pulses were palpable at the ankle but feeble and ankle pressure 20 mmHg. The arterial and venous color Doppler study was within normal limits. Contrast-enhanced computed tomography angiography (CTA) was inconclusive as a radiologist reported that there is evidence of slow flow in the dorsalis pedis and posterior tibial arteries in the foot and advised further investigation. The peripheral angiography was done, which revealed the slow flow in the dorsalis pedis and posterior tibial arteries in the distal leg and foot. Emergency three-compartment decompressive fasciotomy was done. Intraoperative finding showed that the muscles and soft tissue were healthy and bulging of the posterior compartment. The pressure in the posterior compartment was 18 mmHg. There was improvement in pain, and the foot regained the normal color and movements after 2 days of fasciotomy. She was discharged on the 5th day with the advice of wound care (to get daily dressing of the wound) as in the outpatient department.


  Discussion Top


A delay in the diagnosis of acute compartment syndrome can have devastating consequences for the patient. Early suspicion of the disease should invoke an immediate response. Intracompartmental bleeding or edema leads to increased intracompartmental pressure, which increases venous capillary pressure. Capillary collapse occurs when the compartment pressure surpasses the capillary perfusion pressure, leading to cellular ischemia and necrosis. Interstitial edema develops from tissue necrosis and further worsens compartmental swelling.[3] Bacterial infections that are associated with exotoxin release and tissue swelling can also trigger compartment syndrome.[3] The classic signs of acute compartment syndrome include the 6 “P's:” pain, paresthesia, poikilothermia, pallor, paralysis, and pulselessness.[4] Pain is usually the initial complaint and should trigger the workup of acute compartment syndrome. A clinical diagnosis of compartment syndrome can be followed by prompt surgical decompression.[5] Paralysis, pulselessness, and paresthesias present late in the disease process, often after irreversible nerve and muscle damage, and should not routinely be part of the diagnostic criteria for acute compartment syndrome. Fasciotomies performed more than 8 h after injury are associated with a significantly higher risk of infection.[6] One of the biggest pitfalls about fasciotomy for compartment syndrome is missing or inadequately opening a compartment. A missed compartment is a critical technical error as irreversible muscle and nerve damage may occur.[7] Postoperatively, the patient must be frequently examined, and the creatine kinase (CK) levels followed. Failure to clear CK or any other concerns of a missed compartment must trigger immediate re-exploration.[8]

CTA is the investigation of choice after the clinical assessment and Doppler study and rarely needs invasive procedures like peripheral angiography. In our case, as the radiologist was not able to find the exact pathology and advised further investigation, we had to go for peripheral angiography for diagnosis. Every procedure has pitfalls, and one should not hesitate to go for invasive procedures when it is life or limb saving. CTA may have a role in patients with a questionable physical examination, and it appears to be poorly suited as a screening or diagnostic modality in some cases.[9] Kelly et al. used conventional angiography in their cohort of 14 patients after undergoing CTA. Five patients had both physical examination and CTA findings of vascular injury with angiography used during the procedure. The rest of the nine patients had no signs of vascular injury on physical examination or abnormal findings on CTA and did not undergo revascularization.[9] Ordog et al. in a study of 28,000 gunshot wounds recommended the increased use of angiography due to missed nine vascular injuries.[10] Conventional arteriography can differentiate between intimal disruption and spasm through the use of vasodilators, and vascular dissection may only be apparent with conventional angiography.[11]

We are not using invasive angiography routinely but were used in this case only as the conventional techniques were not able to reach the diagnosis. There is very little literature available on the use of conventional angiography in the diagnosis of compartment syndrome, we are of the view where in doubt, this can be of help in diagnosis and favorable outcome, and CTA may have a limited role in arterial spasm and dissection.


  Conclusion Top


Any delay in evaluating and treating patients with lower extremity compartment syndrome can be devastating for the patient. High suspicion is needed to diagnose the condition. The classic signs of compartment syndrome, the “6 P's,” can be deceiving. Our patient neither had any significant history nor the classical signs of acute compartment syndrome. We were not able to diagnose it on routine investigations indicated such as Doppler and CTA, so had to go for the invasive procedure like peripheral angiography. Every procedure has pitfalls, and one should not hesitate to go for invasive procedures when it is life or limb saving. With timely intervention, we were able to save the limb. Fasciotomy is a simple, straightforward treatment that is highly effective if performed at earliest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Donaldson J, Haddad B, Khan WS. The pathophysiology, diagnosis and current management of acute compartment syndrome. Open Orthop J 2014;8:12.  Back to cited text no. 1
    
2.
Branco BC, Inaba K, Barmparas G, Schnüriger B, Lustenberger T, Talving P, et al. Incidence and predictors for the need for fasciotomy after extremity trauma: A 10-year review in a mature level I trauma centre. Injury 2011;42:1157-63.  Back to cited text no. 2
    
3.
Hargens AR, Romine JS, Sipe JC, Evans KL, Mubarak SJ, Akeson H. Peripheral nerve-conduction block by high muscle-compartment pressure. J Bone Joint Surg Am 1979;61:192-200.  Back to cited text no. 3
    
4.
Vaillancourt C, Shrier I, Vandal A, Falk M, Rossignol M, Vernec A, et al. Acute compartment syndrome: How long before muscle necrosis occurs? CJEM 2004;6:147-54.  Back to cited text no. 4
    
5.
Balogh ZJ, Butcher NE. Compartment syndromes from head to toe. Crit Care Med 2010;38 Suppl 9:S445-51.  Back to cited text no. 5
    
6.
Farber A, Tan TW, Hamburg NM, Kalish JA, Joglar F, Onigman T, et al. Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: A review of the National Trauma Data Bank. Injury 2012;43:1486-91.  Back to cited text no. 6
    
7.
Bhattacharya K, Catherine AN. Acute compartment syndrome of the lower leg: Changing concepts. Int J Low Extrem Wounds 2003;2:240-2.  Back to cited text no. 7
    
8.
Badhe S, Baiju D, Elliot R, Rowles J, Calthorpe D. The “silent” compartment syndrome. Injury 2009;40:220-19.  Back to cited text no. 8
    
9.
Kelly SP, Rambau G, Tennent DJ, Osborn PM. The role of CT angiography in evaluating lower extremity trauma: 157 patient case series at a military treatment facility. Mil Med 2019;184:e490-3.  Back to cited text no. 9
    
10.
Ordog G, Wasserberger J, Balasubramanium S, Shoemaker W. Civilian gunshot wounds outpatient management. J Trauma1994;36:106-11.  Back to cited text no. 10
    
11.
Ravari H, Pezeshki Rad M, Bahadori A, Ajami O. Comparison of conventional angiographic findings between trauma patients with or without runoff. Bull Emerg Trauma 2014;2:72-6.  Back to cited text no. 11
    




 

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