A 15-year-old male football player presented acutely following an injury to their left knee. He described violently kicking the ground, instead of the ball, while attempting to score. This involved a violent contraction of the quadriceps muscle against a fixed tibia. Immediately following the injury he was unable to weight-bear and reported severe pain in the knee and lower leg. He was taken to hospital via ambulance. When he was seen in the emergency room several hours after his injury there was a tense effusion in the knee, generalised tenderness over the anterior tibia and an inability to straight leg raise. The muscles of the lower limb were tense and tender to palpation, and there was pain with passive ankle movements. There was global altered sensation over the lower limb.
X-rays taken at the time of injury show a fracture involving the proximal tibial epiphysis. The tibial tuberosity is hinged upwards anteriorly. No high-tech imaging (CT or MRI scans) were performed. Post-operative images show that the fracture has been reduced and stabilized with a percutaneous screw. A final follow-up x-ray series (taken approximately nine months after the injury) shows that the fracture has healed and that the screw has been removed.
Due to the clinical concerns about a compartment syndrome of the lower leg (as well as the need to address the fracture) the player was immediately transferred to the operating room, where the fracture was reduced and fixated by screw. After confirmation of elevated intra-compartmental pressure, and no evidence of a vascular injury, a surgical fasciotomy from the lateral side of the shank with opening of all four compartments was performed. Five days after initial surgery, the fasciotomy wound was closed completely. The player was in hospital for a total of seven days. At the time of his discharge he was able to partial weight-bear on crutches. Full weight-bearing was achieved six weeks after surgery. Six months after surgery the screw was removed. Nine months after surgery he was back playing football without complication.
Acute compartment syndrome of the lower leg is a rare but serious complication following either fractures or soft tissue injuries. If this is not identified quickly, and treated with a fasciotomy, serious muscle and nerve damage can occur. Acute compartment syndrome can occur after both closed and open tibial fractures. The diagnosis is primarily clinical with confirmation by direct measurement of compartment pressure. Younger patients may be more likely to experience compartment syndrome. This may reflect the fact that they are more active and participate in sports that may have an increased risk of trauma. Alternatively this may be because younger patients have relative muscle hypertrophy (compared with older patients with muscle atrophy) and as a result have less ‘space’ for muscle expansion. Pain is generally the most common presenting complaint and is can be disproportionate to the injury severity. Other common signs and symptoms include a feeling of tightness, paresthesia, muscle weakness, and diminished or absent pulses. The diagnosis can be confirmed via measurement of compartment pressures through needle manometry. The treatment of choice, as this case illustrates, is urgent fasciotomy. In adults, delay in treatment of as little as eight hours has been shown to cause permanent and irreversible skeletal muscle deficits. Fasciotomy is recommended when compartment pressure rises to within 30 mm Hg of the diastolic pressure although some clinicians believe that this figure is too low.
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