Acute compartment syndrome of the foot due to a twisting injury while playing sports

Background

Acute ankle sprain is a common injury accounting for approximately 25% of all musculoskeletal injuries and, following an inversion-type mechanism, the lateral ankle ligament complex can be susceptible to rupture necessitating treatment.1 2 Ankle injuries are very common in field sports, the frequency of which may be attributed to the contact nature of the sport in question, but also the ankle movements involved, for example the quick change of direction required to keep up with play along with repetitive landing on one foot.3 These movements can lead to a disparity of rotational and angular stresses to the ankle joint. In the setting of amateur field sports, it is argued that players are at increased risk as they present with lower fitness and skill levels than professionals leading to more player contact and inappropriate ankle movements.4 5

Acute compartment syndrome (ACS) may result from intrinsic or extrinsic causes, oedema or haemorrhage occurring following an acute injury. This can lead to a rise in intracompartmental pressure and the subsequent development of ACS.6 The authors believe that acute haemorrhage and resultant haematoma formation were key aetiological factors in this case.

While ACS, isolated to a single foot compartment is a rare occurrence, clinicians need to be aware of this potentially devastating condition and to always remain cognisant of it when reviewing ankle sprain injuries. Furthermore, it is essential that all members of the multidisciplinary team remain vigilant in their attentiveness for signs of the condition developing to ensure timely intervention and the avoidance of irreversible damage.7 8

Case presentation

A 25-year-old man was admitted to the Trauma and Orthopaedic Unit after presenting to the emergency department 2 hours after a twisting injury of his right ankle while playing rugby. The patient was presented with pain and swelling around the ankle and into the lateral aspect of the foot. Plain X-rays of the foot and ankle revealed no evidence of a fracture (figures 1 and 2) and due to significant pain and swelling the patient was referred to the orthopaedic team on call for further assessment.

The patient’s clinical condition continued to deteriorate with worsening swelling, patchy paleness over the anterolateral aspect of the ankle (figures 3 and 4) and pain despite administration of analgesia. Lateral osteofascial compartment pressure of the right foot was measured revealing an intra-compartmental pressure >30 mm Hg and the patient was immediately brought to the operating room for an emergency fasciotomy under general anaesthesia.

Treatment

The patient was placed supine on the operating table and standard prep and drape performed. There was no local anaesthetic or tourniquet used. An incision was made over the fourth dorsal webspace and another incision over a medial aspect of the foot. The nine compartments were released through a medial and dorsolateral approach. On inspection, the muscle was of the appropriate colour and retained its contractility and consistency. A large quantity of haematoma was evacuated from the lateral compartment arising from the anterolateral ankle most likely originating from a disrupted branch of the peroneal artery. After wound/tissue toilet with 3 L of normal saline solution, wound edges were approximated with the help of clips and vessel loops (figures 5 and 6). Two days post-op, the surgical wounds were closed without any increased tension (figure 7).

Outcome and follow-up

Day 3 post-op an MRI scan of the foot and ankle was performed and revealed a full-thickness tear of the anterior talofibular and calcaneofibular ligament (figure 8). The peroneal artery was not commented on in the initial report which described extensive inflammatory changes surrounding the anterior talofibular ligament and the calcaneofibular ligament. The authors discussed the case with the reporting radiologist and peroneal artery integrity was confirmed but significant inflammatory changes over the lateral aspect of the ankle made it difficult to comment on branches of the peroneal artery which may have caused the haematoma formation.

The total duration of hospital admission was 6 days. Follow-up was done at 1 week, 2 weeks and 6 weeks and the patient scored 80 on the Lower Extremity Functional Scale (validated patient-reported outcome measure for which highest score is 80, indicative of no functional impairment) at 1 year post-op. The patient is now fully mobile and back to sports with no reported deficits.