After a punch: recurrence of compartment syndrome following minor trauma

After a punch: recurrence of compartment syndrome following minor trauma Acute compartment syndrome (ACS) is a diagnosis that requires high-clinical suspicion especially in cases when the initial causal event could be considered insignificant. We present a novel case presentation of ACS associated with minor trauma in a patient with a previous history of compartment syndrome in the same extremity from a motor vehicle accident 10 years prior to presentation. To the best of our knowledge, this is the first reported case of recurrent ACS. Due to the possibility of significant morbidity, including loss of limb, it is imperative to recognize the presentation quickly so proper surgical inter- vention can occur. This case shows compartment syndrome can occur after a low impact mechanism of injury and previous compartment syndrome may be a risk factor, lowering the threshold for a re-occurrence. Serial exams and compartment pressure measurements should be used to aid recognition in ambiguous clinical presentations. INTRODUCTION upper extremity after striking a heavy bag with an uppercut Acute compartment syndrome (ACS) is an increase in pressure of a punch. At the time of event, the patient felt a sudden sharp pain closed fascial space that is significant enough to compromise per- radiating from the wrist to the elbow, which eventually localized fusion to tissues enclosed in that space. To avoid neurovascular to the elbow. Over the next 2 days, the patient gradually developed complications, emergent fasciotomy is imperative for relieving that swelling and diffuse erythema from the proximal aspect of the pressure. Compartment syndrome is normally associated with a right arm to the wrist, tension, and decreased elbow, wrist and fin- high energy traumatic event but multiple reports have noted cases ger mobility. He reported a history of compartment syndrome that show a multifactorial causation. Understanding all the pos- requiring fasciotomy in his right distal arm and proximal forearm sible associated factors is important for maintaining high-clinical due to an automobile accident-induced crush injury 10 years prior. suspicion so the emergent nature of these cases can be realized. On exam, he was tender to palpation, weak to grip, but had intact This case shows a high energy mechanism of injury is not always sensation and vasculature. Initially, cellulitis was suspected, needed and the possibility that previous history may be associated partly because of the appearance of his extremity and an unlikely with an increased risk of future compartment syndrome. traumatic mechanism for ACS. Radiographs were unremarkable for fractures. Magnetic resonance imaging (MRI) revealed exten- sive edema in the proximal brachioradialis muscle and extensor CASE REPORT carpi radialis longus muscle, as well as increased signal in the A previously healthy male in his 30s presented to the emergency extensor musculature at the dorsal aspect of the arm, but no frac- department with a 2-day history of pain and swelling in his right ture or tendinous, ligamentous or muscular tear (Fig. 1). Received: October 13, 2017. Accepted: January 13, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy011/4841779 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 S. Ryndin et al. Figure 1: White arrows: high-grade muscle strain of the muscles the dorsal compartment with extensive soft tissue edema throughout the arm. Ultrasound showed a non-occlusive thrombus in the right axillary pain out of proportion to injury, weakness and questionable and brachial veins, for which the patient was eventually started tense compartment. on anticoagulation. All initial labs were unremarkable except the ACS in the forearm is most commonly caused by fractures at CPK of 973 and the patient was subsequently admitted. the distal radius (34%) or diaphysis of both radius and ulna (30%), On hospital Day 4, due to lack of improvement on antibiotics, with a third of cases not associated with a fracture [5]. A study by worseningofpain and growingsuspicion forACS,the patient Hope et al.[7] found that ACS without a preceding fracture has was taken to the operating room (OR). After dissection of the been associated with longer times to diagnosis and operative fascia, it was found that the muscles of the mobile wad had a intervention, which was the case with our patient. Given the ini- dark and dusky appearance along with an associated hematoma, tial impression of cellulitis, an unusual mechanism of trauma, consistent with the diagnosis of ACS. The hematoma was evacu- lack of fractures and soft tissue tears and non-specific findings on ated and vacuum assisted closure of the wound was performed exam,the diagnosisofACS wasnot considered untillater,as the (wound VAC). Four days later, the wound was re-examined in the patient was clinically worsening. Fortunately, despite a 6-day OR, and the muscles looked pink without signs of necrosis. The delay from the onset of symptoms to fasciotomy, the vascular wound VAC was removed and the incision was primarily closed. compromise was not severe enough to cause tissue anoxia, as During his stay, the patient developed acute renal failure pre- there was no gross myonecrosis on intra-op exam and no neuro- sumed to be due to rhabdomyolysis-induced myoglobinuria. The logical sequelae. This is unusual, as a delay in over 12 h almost renal failure subsequently resolved and the patient was dis- invariably causes long-term sequelae [8]. We suspect that this charged home with no residual symptoms. mighthavebeendue to the factthatthe compartment was at least partially released with prior fasciotomy, allowing pressures to build up more gradually and hence have a less traumatic effect on enclosed muscular and neural tissue. This case shows previ- DISCUSSION ous history of compartment syndrome may increase the risk of ACS is a rare condition with a disproportionately higher annual recurrent episodes. It also helps to highlight the multifactorial incidence in males than in females [1]. Fracture is the most com- nature of compartment syndrome and closer and/or longer obser- mon inciting event, with about 83% of ACS cases in adults pre- vation may be needed due to the possible delay in presentation. ceded by fractures, most commonly tibial [2]. Other factors Maintaining a high clinical suspicion along with serial exams and associated with the development of ACS include crush injuries, measuring compartment pressures in all suspected cases are bleeding disorders, anticoagulation, septicemia, animal bites, important factors in preventing morbidity in these cases. arterial damage and venous cannulation [1, 3]. The potential for significant morbidity makes it necessary for constant consider- ation and constitutes an orthopedic emergency. ACS can lead to ACKNOWLEDGEMENTS complications including muscle necrosis, contractures, neuro- None. logical deficits, infections, rhabdomyolysis, hyperkalemia, myo- globinuria, chronic pain and even amputation [1, 4, 5]. As the time to fasciotomy increases, the likelihood of developing these CONFLICT OF INTEREST STATEMENT complications increases, and monitoring compartment pressures There are no conflicts of interest to declare. has been shown to reduce time to surgery [5, 6]. However, com- partment pressures are not always monitored prior to fasciot- omy, and in the cases of forearm ACS, it is monitored in only FUNDING 50% of patients [5]. The other half of patients proceed to the OR There is no financial or non-financial support to declare. based on the high index of suspicion due to clinical findings such as edema, tension to extremity palpation, and the classic six Ps of compartment syndrome—pain, paresthesia, paresis, pallor, AUTHORS’ CONTRIBUTIONS poikilothermic and pulselessness. Edema is the only sensitive clinical finding, present in 100% of cases, while others like the six Stanislav Ryndin, D.O., primary author, literature reviewer and Ps have poor sensitivity [5]. Our patient presented with edema, case organization. Andrew Delozier, M.D., co-author, literature Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy011/4841779 by Ed 'DeepDyve' Gillespie user on 16 March 2018 After a punch: recurrence of compartment syndrome following minor trauma 3 reviewer and case organization. Michael Stanley, D.O., co-author 2. Zuchelli D, Divaris N, McCormack JE, Huang EC, Chaudhary and advisor. ND, Vosswinkel JA, et al. Extremity compartment syndrome following blunt trauma: a level I trauma center’s 5-year experience. J Surg Res 2017;217:131–6. DISCLOSURES 3. Reynolds JM, Christophersen C, Mulcahey MK. Acute com- None. partment syndrome after an olecranon fracture in a patient with mild hemophilia B. J Orthop Case Rep 2017;7:98–101. CONSENT 4. Smith K, Wolford RW. Acute idiopathic compartment syn- drome of the forearm in an adolescent. West J Emerg Med No. All patient identifying information is removed. 2015;16:158–60. 5. Duckworth AD, Mitchell SE, Molyneux SG, White TO, Court- DECLARATIONS Brown CM, McQueen MM. Acute compartment syndrome of the forearm. J Bone Joint Surg Am 2012;94:e63. This is an original article and has not been published or sub- 6. Roberts S, Thomas P. Acute compartment syndrome in tibial mitted elsewhere. diaphyseal fractures. J Bone Joint Surg Br 1996;78:683. 7. Hope MJ, McQueen MM. Acute compartment syndrome in REFERENCES the absence of fracture. J Orthop Trauma 2004;18:220–4. 1. McQueen MM, Gaston P, Court-Brown CM. Acute compart- 8. Crawford B, Comstock S. Acute compartment syndrome of ment syndrome. Who is at risk? J Bone Joint Surg Br 2000;82: the dorsal forearm following noncontact injury. CJEM 2010; 200–3. 12:453–6. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy011/4841779 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

After a punch: recurrence of compartment syndrome following minor trauma

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

Acute compartment syndrome (ACS) is a diagnosis that requires high-clinical suspicion especially in cases when the initial causal event could be considered insignificant. We present a novel case presentation of ACS associated with minor trauma in a patient with a previous history of compartment syndrome in the same extremity from a motor vehicle accident 10 years prior to presentation. To the best of our knowledge, this is the first reported case of recurrent ACS. Due to the possibility of significant morbidity, including loss of limb, it is imperative to recognize the presentation quickly so proper surgical inter- vention can occur. This case shows compartment syndrome can occur after a low impact mechanism of injury and previous compartment syndrome may be a risk factor, lowering the threshold for a re-occurrence. Serial exams and compartment pressure measurements should be used to aid recognition in ambiguous clinical presentations. INTRODUCTION upper extremity after striking a heavy bag with an uppercut Acute compartment syndrome (ACS) is an increase in pressure of a punch. At the time of event, the patient felt a sudden sharp pain closed fascial space that is significant enough to compromise per- radiating from the wrist to the elbow, which eventually localized fusion to tissues enclosed in that space. To avoid neurovascular to the elbow. Over the next 2 days, the patient gradually developed complications, emergent fasciotomy is imperative for relieving that swelling and diffuse erythema from the proximal aspect of the pressure. Compartment syndrome is normally associated with a right arm to the wrist, tension, and decreased elbow, wrist and fin- high energy traumatic event but multiple reports have noted cases ger mobility. He reported a history of compartment syndrome that show a multifactorial causation. Understanding all the pos- requiring fasciotomy in his right distal arm and proximal forearm sible associated factors is important for maintaining high-clinical due to an automobile accident-induced crush injury 10 years prior. suspicion so the emergent nature of these cases can be realized. On exam, he was tender to palpation, weak to grip, but had intact This case shows a high energy mechanism of injury is not always sensation and vasculature. Initially, cellulitis was suspected, needed and the possibility that previous history may be associated partly because of the appearance of his extremity and an unlikely with an increased risk of future compartment syndrome. traumatic mechanism for ACS. Radiographs were unremarkable for fractures. Magnetic resonance imaging (MRI) revealed exten- sive edema in the proximal brachioradialis muscle and extensor CASE REPORT carpi radialis longus muscle, as well as increased signal in the A previously healthy male in his 30s presented to the emergency extensor musculature at the dorsal aspect of the arm, but no frac- department with a 2-day history of pain and swelling in his right ture or tendinous, ligamentous or muscular tear (Fig. 1). Received: October 13, 2017. Accepted: January 13, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy011/4841779 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 S. Ryndin et al. Figure 1: White arrows: high-grade muscle strain of the muscles the dorsal compartment with extensive soft tissue edema throughout the arm. Ultrasound showed a non-occlusive thrombus in the right axillary pain out of proportion to injury, weakness and questionable and brachial veins, for which the patient was eventually started tense compartment. on anticoagulation. All initial labs were unremarkable except the ACS in the forearm is most commonly caused by fractures at CPK of 973 and the patient was subsequently admitted. the distal radius (34%) or diaphysis of both radius and ulna (30%), On hospital Day 4, due to lack of improvement on antibiotics, with a third of cases not associated with a fracture [5]. A study by worseningofpain and growingsuspicion forACS,the patient Hope et al.[7] found that ACS without a preceding fracture has was taken to the operating room (OR). After dissection of the been associated with longer times to diagnosis and operative fascia, it was found that the muscles of the mobile wad had a intervention, which was the case with our patient. Given the ini- dark and dusky appearance along with an associated hematoma, tial impression of cellulitis, an unusual mechanism of trauma, consistent with the diagnosis of ACS. The hematoma was evacu- lack of fractures and soft tissue tears and non-specific findings on ated and vacuum assisted closure of the wound was performed exam,the diagnosisofACS wasnot considered untillater,as the (wound VAC). Four days later, the wound was re-examined in the patient was clinically worsening. Fortunately, despite a 6-day OR, and the muscles looked pink without signs of necrosis. The delay from the onset of symptoms to fasciotomy, the vascular wound VAC was removed and the incision was primarily closed. compromise was not severe enough to cause tissue anoxia, as During his stay, the patient developed acute renal failure pre- there was no gross myonecrosis on intra-op exam and no neuro- sumed to be due to rhabdomyolysis-induced myoglobinuria. The logical sequelae. This is unusual, as a delay in over 12 h almost renal failure subsequently resolved and the patient was dis- invariably causes long-term sequelae [8]. We suspect that this charged home with no residual symptoms. mighthavebeendue to the factthatthe compartment was at least partially released with prior fasciotomy, allowing pressures to build up more gradually and hence have a less traumatic effect on enclosed muscular and neural tissue. This case shows previ- DISCUSSION ous history of compartment syndrome may increase the risk of ACS is a rare condition with a disproportionately higher annual recurrent episodes. It also helps to highlight the multifactorial incidence in males than in females [1]. Fracture is the most com- nature of compartment syndrome and closer and/or longer obser- mon inciting event, with about 83% of ACS cases in adults pre- vation may be needed due to the possible delay in presentation. ceded by fractures, most commonly tibial [2]. Other factors Maintaining a high clinical suspicion along with serial exams and associated with the development of ACS include crush injuries, measuring compartment pressures in all suspected cases are bleeding disorders, anticoagulation, septicemia, animal bites, important factors in preventing morbidity in these cases. arterial damage and venous cannulation [1, 3]. The potential for significant morbidity makes it necessary for constant consider- ation and constitutes an orthopedic emergency. ACS can lead to ACKNOWLEDGEMENTS complications including muscle necrosis, contractures, neuro- None. logical deficits, infections, rhabdomyolysis, hyperkalemia, myo- globinuria, chronic pain and even amputation [1, 4, 5]. As the time to fasciotomy increases, the likelihood of developing these CONFLICT OF INTEREST STATEMENT complications increases, and monitoring compartment pressures There are no conflicts of interest to declare. has been shown to reduce time to surgery [5, 6]. However, com- partment pressures are not always monitored prior to fasciot- omy, and in the cases of forearm ACS, it is monitored in only FUNDING 50% of patients [5]. The other half of patients proceed to the OR There is no financial or non-financial support to declare. based on the high index of suspicion due to clinical findings such as edema, tension to extremity palpation, and the classic six Ps of compartment syndrome—pain, paresthesia, paresis, pallor, AUTHORS’ CONTRIBUTIONS poikilothermic and pulselessness. Edema is the only sensitive clinical finding, present in 100% of cases, while others like the six Stanislav Ryndin, D.O., primary author, literature reviewer and Ps have poor sensitivity [5]. Our patient presented with edema, case organization. Andrew Delozier, M.D., co-author, literature Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy011/4841779 by Ed 'DeepDyve' Gillespie user on 16 March 2018 After a punch: recurrence of compartment syndrome following minor trauma 3 reviewer and case organization. Michael Stanley, D.O., co-author 2. Zuchelli D, Divaris N, McCormack JE, Huang EC, Chaudhary and advisor. ND, Vosswinkel JA, et al. Extremity compartment syndrome following blunt trauma: a level I trauma center’s 5-year experience. J Surg Res 2017;217:131–6. DISCLOSURES 3. Reynolds JM, Christophersen C, Mulcahey MK. Acute com- None. partment syndrome after an olecranon fracture in a patient with mild hemophilia B. J Orthop Case Rep 2017;7:98–101. CONSENT 4. Smith K, Wolford RW. Acute idiopathic compartment syn- drome of the forearm in an adolescent. West J Emerg Med No. All patient identifying information is removed. 2015;16:158–60. 5. Duckworth AD, Mitchell SE, Molyneux SG, White TO, Court- DECLARATIONS Brown CM, McQueen MM. Acute compartment syndrome of the forearm. J Bone Joint Surg Am 2012;94:e63. This is an original article and has not been published or sub- 6. Roberts S, Thomas P. Acute compartment syndrome in tibial mitted elsewhere. diaphyseal fractures. J Bone Joint Surg Br 1996;78:683. 7. Hope MJ, McQueen MM. Acute compartment syndrome in REFERENCES the absence of fracture. J Orthop Trauma 2004;18:220–4. 1. McQueen MM, Gaston P, Court-Brown CM. Acute compart- 8. Crawford B, Comstock S. Acute compartment syndrome of ment syndrome. Who is at risk? J Bone Joint Surg Br 2000;82: the dorsal forearm following noncontact injury. CJEM 2010; 200–3. 12:453–6. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy011/4841779 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Feb 1, 2018

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