|Year : 2021 | Volume
| Issue : 3 | Page : 261-263
Lower leg compartment syndrome detected by peripheral angiography
Sanjeev Kumar Singla
Department of Anaesthesia and Intensive Care, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
|Date of Submission||24-Aug-2020|
|Date of Decision||15-Oct-2020|
|Date of Acceptance||17-Oct-2020|
|Date of Web Publication||6-Jul-2021|
Sanjeev Kumar Singla
Department of Anaesthesia and Intensive Care, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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. 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. 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|| |
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|| |
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. Bacterial infections that are associated with exotoxin release and tissue swelling can also trigger compartment syndrome. The classic signs of acute compartment syndrome include the 6 “P's:” pain, paresthesia, poikilothermia, pallor, paralysis, and pulselessness. 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. 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. 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. 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.
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. 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. Ordog et al. in a study of 28,000 gunshot wounds recommended the increased use of angiography due to missed nine vascular injuries. Conventional arteriography can differentiate between intimal disruption and spasm through the use of vasodilators, and vascular dissection may only be apparent with conventional angiography.
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|| |
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
Conflicts of interest
There are no conflicts of interest.
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