a spontaneus cs in patient diabetic

of 3 /3
1068 CASE REPORTS THE JOURNAL OF BONE AND JOINT SURGERY tive accuracy. External xation allows per- and post-operative adjustment and thus high accuracy, but poor comfort. FAN has a steep learning curve. Good quality intra-operative radiographs are a prerequisite for accuracy. The total treatment time is less than with other techniques. In these two cases, the te ch- nique did not create any limb length inequality. No benets in any form have been received or will be received from a commer- cial party related directly or indirectly to the subject of this article. References 1. Smyth EHJ. Windswept deformity. J Bone Joint Surg [Br] 1980;62-B:166-7. 2. Manki n HJ. Rickets, osteomalacia and renal osteodystrophy: an update. Orthop Clin North Am 1990;21:81-96. 3. Paley D, Herzenberg JE, Bor N. Fixator assisted nailing of femoral and tibial deformities. Tech Orth 1997;12:260-75. 4. Paley D, Herzenberg JE, T etsworth K, McKie J, Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am 1994;25:425-65. 5. Stanitski DF. Treat ment of deformity secondary to metabolic bone disease with Ili za- roc technique. Clin Orthop 1994;301:38-41.  CASE REPORT A spontaneous compartment syndrome in a patient with diabetes R. M. Jose, N. Viswanathan, E. Aldlyami, Y. Wilson, N. Moiemen, R. Thomas From Department of Plastic Surgery, Selly Oak Hospital, Birmingham, UK  R. M. Jose, MB BS, MCh, FRCS, Senior House Ofcer  N. Viswanathan, MB BS, FRCS, Registrar  E. Aldlyami, MBChB, MRCS, Senior House Ofcer  Y. Wilson, MBChB, FRCS, Consultant  N. Moiemen, MBBCh, FRCS, Consultant Department of Plastic Surgery, Selly Oak Hospital, Birmingham B29 6JD, UK.  R. Thomas, MB BS, MRCS, LRCP, Consultant Department of Trauma and Orthopaedics, New Cross Hospital, Wolverhampton WV10 0QP, West Midlands, UK. Correspondence should be sent to Mr R. M. Jose. ©2004 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.86B7. 14770 $2.00 J Bone Joint Surg [Br] 2004;86-B:1068-70. Received 9 July 2003; Accepted after revision 16 October 2003 A compartment syndrome is an orthopaedic emergency which can result from a variety of causes, the most common being trauma. Rarely, it can develop spontaneously and several aetiologies for spontaneous compartment syndrome have been described. We describe a patient with diabetes who developed a spontaneous compartment syndrome. The diagnosis was delayed because of the atypical presentation. Compartment syndrome is dened as an elevation o f the interstitial pressure in a closed osteofascial com- partment causing microvascular compromise. The common causes include trauma, arterial injury, limb compression and burns. Rarely, it can also occur spontaneously in association with type-I diabetes mellitus, 1-4  hypothyroidis m, 5  inuenza-vir us-induced myositis, 6  leukaemic inltration, 7  the nephrotic syn- drome, 8  a ruptured aneurysm, 9  anticoagulation 10 and a ganglion cyst. 11  Four cases of spontaneous compartment syndrome in diabetics have been described previously and many theories regarding the aetiology have been advanced, including meta- bolic changes giving rise to increased uid pressure in the osteofascial compartment, vascular occlusion and muscle necrosis. Case report A 47-year-old man of Asian origin developed pain in the anterolateral aspect of the left leg after a brief walk. It was moderate in intensity but was not relieved by rest. He had suffered from type-I diabe- tes mellitus, well controlled on insulin, for almost 20 years. He was also hypertensive and was und ergoing laser treatment for diabetic retinopathy. He attended the Emergency Department with a localised red, tender area over the upper lateral aspect of the left leg below the knee. No denite diagnosis was made and he was given analgesics and discharged. The pain was not relieved and he was prescribed stronger analgesics by his general practi- tioner. The pain increased in intensity over the next four days and he developed foot drop. He was seen again and referred for an orthopaedic opinion. There was swelling, redness and tenderness over the anterolateral aspect of the left leg. He had normal sensation but was unable to dorsiex his foot. Both the dorsalis pedis and posterior tibial pulses were present. The differential diagnoses w ere an intrafascial bleed, infection, spontaneous muscle necrosis or a compartment syndrome. Haematological investigation revealed a mild leu- kocytosis (12.8 x 10 9  /l). Biochemical analysis was normal except that the level of creatine kinase was increased to 4178 U/l, raising the suspicion of muscle necrosis and a compartment syndrome. Decompression of the anterior and lateral compart- ments was carried out. The muscles were found to bulge beneath the deep fascia and the compartmen- tal pressure was raised. Both muscle groups appeared to be ischaemic and did not respond to pinching. The pain persisted and he was taken back to theatre after two days. Necrotic parts of tibialis anterior were excised and sent for histological examination. The wound was left open and dressed regularly. At one week it was closed secondarily, without a skin graft. Histological examination of the excised specimen showed areas of devitalised skeletal muscle without evidence of inammation. There were some viable atrophic muscle bres (Fig. 1) with blood vessels showing thrombus and recanalisation (Fig. 2).

Author: akbar-rizki-ar

Post on 03-Jun-2018

218 views

Category:

Documents


0 download

Embed Size (px)

TRANSCRIPT

  • 8/12/2019 A Spontaneus CS in Patient Diabetic

    1/3

    1068 CASE REPORTS

    THE JOURNAL OF BONE AND JOINT SURGERY

    tive accuracy. External fixation allows per- and post-operative

    adjustment and thus high accuracy, but poor comfort.

    FAN has a steep learning curve. Good quality intra-operative

    radiographs are a prerequisite for accuracy. The total treatment

    time is less than with other techniques. In these two cases, the tech-

    nique did not create any limb length inequality.

    No benefits in any form have been received or will be received from a commer-

    cial party related directly or indirectly to the subject of this article.

    References1. Smyth EHJ. Windswept deformity. J Bone Joint Surg [Br] 1980;62-B:166-7.

    2. Mankin HJ. Rickets, osteomalacia and renal osteodystrophy: an update. Orthop ClinNorth Am 1990;21:81-96.

    3. Paley D, Herzenberg JE, Bor N. Fixator assisted nailing of femoral and tibialdeformities. Tech Orth 1997;12:260-75.

    4. Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning forfrontal and sagittal plane corrective osteotomies. Orthop Clin North Am 1994;25:425-65.

    5. Stanitski DF. Treatment of deformity secondary to metabolic bone disease with Ili za-

    roc technique. Clin Orthop 1994;301:38-41.

    CASE REPORT

    A spontaneous compartment syndrome in apatient with diabetes

    R. M. Jose,N. Viswanathan,E. Aldlyami,Y. Wilson,N. Moiemen,R. Thomas

    From Department of

    Plastic Surgery, Selly

    Oak Hospital,

    Birmingham, UK

    R. M. Jose, MB BS, MCh,FRCS, Senior House Officer

    N. Viswanathan, MB BS,

    FRCS, Registrar

    E. Aldlyami, MBChB,MRCS, Senior House Officer

    Y. Wilson, MBChB, FRCS,

    Consultant

    N. Moiemen, MBBCh,FRCS, Consultant

    Department of Plastic

    Surgery, Selly Oak Hospital,

    Birmingham B29 6JD, UK.

    R. Thomas, MB BS, MRCS,

    LRCP, Consultant

    Department of Trauma andOrthopaedics, New Cross

    Hospital, Wolverhampton

    WV10 0QP, West Midlands,UK.

    Correspondence should be

    sent to Mr R. M. Jose.

    2004 British Editorial

    Society of Bone and

    Joint Surgery

    doi:10.1302/0301-620X.86B7.14770 $2.00

    J Bone Joint Surg [Br]

    2004;86-B:1068-70.

    Received 9 July 2003;

    Accepted after revision

    16 October 2003

    A compartment syndrome is an orthopaedic emergency which can result from a variety of

    causes, the most common being trauma. Rarely, it can develop spontaneously and several

    aetiologies for spontaneous compartment syndrome have been described. We describe a patient

    with diabetes who developed a spontaneous compartment syndrome. The diagnosis was

    delayed because of the atypical presentation.

    Compartment syndrome is defined as an elevation of

    the interstitial pressure in a closed osteofascial com-

    partment causing microvascular compromise. The

    common causes include trauma, arterial injury, limb

    compression and burns. Rarely, it can also occur

    spontaneously in association with type-I diabetesmellitus,1-4hypothyroidism,5influenza-virus-induced

    myositis,6leukaemic infiltration,7the nephrotic syn-

    drome,8 a ruptured aneurysm,9 anticoagulation10

    and a ganglion cyst.11 Four cases of spontaneous

    compartment syndrome in diabetics have been

    described previously and many theories regarding

    the aetiology have been advanced, including meta-

    bolic changes giving rise to increased fluid pressure

    in the osteofascial compartment, vascular occlusion

    and muscle necrosis.

    Case reportA 47-year-old man of Asian origin developed pain in

    the anterolateral aspect of the left leg after a brief

    walk. It was moderate in intensity but was not

    relieved by rest. He had suffered from type-I diabe-

    tes mellitus, well controlled on insulin, for almost 20

    years. He was also hypertensive and was undergoing

    laser treatment for diabetic retinopathy.

    He attended the Emergency Department with a

    localised red, tender area over the upper lateral

    aspect of the left leg below the knee. No definite

    diagnosis was made and he was given analgesics and

    discharged. The pain was not relieved and he was

    prescribed stronger analgesics by his general practi-

    tioner. The pain increased in intensity over the next

    four days and he developed foot drop. He was seen

    again and referred for an orthopaedic opinion.

    There was swelling, redness and tenderness over

    the anterolateral aspect of the left leg. He had

    normal sensation but was unable to dorsiflex hisfoot. Both the dorsalis pedis and posterior tibial

    pulses were present. The differential diagnoses were

    an intrafascial bleed, infection, spontaneous muscle

    necrosis or a compartment syndrome.

    Haematological investigation revealed a mild leu-

    kocytosis (12.8 x 109/l). Biochemical analysis was

    normal except that the level of creatine kinase was

    increased to 4178 U/l, raising the suspicion of

    muscle necrosis and a compartment syndrome.

    Decompression of the anterior and lateral compart-

    ments was carried out. The muscles were found to

    bulge beneath the deep fascia and the compartmen-

    tal pressure was raised. Both muscle groups

    appeared to be ischaemic and did not respond to

    pinching. The pain persisted and he was taken back

    to theatre after two days. Necrotic parts of tibialis

    anterior were excised and sent for histological

    examination. The wound was left open and dressed

    regularly. At one week it was closed secondarily,

    without a skin graft.

    Histological examination of the excised specimen

    showed areas of devitalised skeletal muscle without

    evidence of inflammation. There were some viable

    atrophic muscle fibres (Fig. 1) with blood vessels

    showing thrombus and recanalisation (Fig. 2).

  • 8/12/2019 A Spontaneus CS in Patient Diabetic

    2/3

    CASE REPORTS 1069

    VOL. 86-B, No. 7, SEPTEMBER 2004

    He was reviewed in the Outpatient Clinic after two weeks when

    his wound had healed. There has been no improvement in the foot

    drop. He continues to attend for physiotherapy and a tendon

    transfer is being considered.

    DiscussionSpontaneous compartment syndrome has been reported in influen-

    zal myositis, hypothyroidism, leukaemic infiltration, nephrotic

    syndrome, vascular anomalies, anticoagulant therapy and cystic

    lesions.5-11There have been four other case reports of spontaneous

    compartment syndrome in diabetes mellites.1-4

    In 1997 Chautems et al1 described a similar case when the

    patient was operated on within eight hours of the onset of symp-

    toms. He suffered no neurological deficit. Smith and Laing2

    reported a case of bilateral compartment syndrome in a diabetic

    patient who presented to the Emergency Department after four

    days. He was found to have muscle necrosis, a bilateral sensory

    deficit in the distribution of the deep peroneal nerve, and a foot

    drop. The delay in the diagnosis of compartment syndrome in our

    patient may be excused by its atypical presentation. Initially, he

    had localised swelling and only moderate pain. Absence of pain

    has been reported previously by Ciacci et al, 12who suggested a

    possible neurapraxic block of the deep peroneal nerve as an expla-

    nation.

    There are two conflicting views regarding the development of

    spontaneous compartment syndrome in diabetics. One suggests

    that metabolic disturbances cause osmotic accumulation of fluid

    in the muscle which may be the primary event leading to

    increased pressure.13The muscle necrosis develops as a result of

    the ischaemia.14The other view is that spontaneous muscle in-

    farction, because of microvascular blockage, is the primary

    event and that compartmental pressures rise subsequent to

    that.2,4We prefer the latter explanation since our patient had alocalised swelling initially and the symptoms progressed over

    several days. The histopathology of the excised muscle showed

    thrombi in the small blood vessels with attempts at recanalisa-

    tion (Fig. 2). A relevant coincidence is that our patient, and two

    other reported patients, had diabetic retinopathy which suggests

    coexisting microvascular disease. There have been other record-

    ed cases of spontaneous muscle infarction in diabetics. They are

    common in type-I diabetes and are strongly associated with

    other microvascular complications such as neuropathy, retino-

    pathy and nephropathy.15 The usual presentation has been a

    swelling in the muscles of the thigh and the treatment has

    Fig. 1

    Necrotic pale muscle bundles bereft of nuclei surrounded by viablemuscle fibres possessing nuclei (haematoxylin and eosin, x2).

    Fig. 2

    A medium calibre septal blood vessel showing recanalisation withfocal, residual intraluminal thrombus (haematoxylin and eosin, x10)

  • 8/12/2019 A Spontaneus CS in Patient Diabetic

    3/3

    1070 CASE REPORTS

    THE JOURNAL OF BONE AND JOINT SURGERY

    mostly been conservative.16,17Since the compartment in the calf

    is smaller and tighter, swelling within it can easily result in a

    compartment syndrome. Early surgery is more likely to be cur-

    ative.

    No benefits in any form have been received or will be received from a commer-

    cial party related directly or indirectly to the subject of this article.

    References1. Chautems RC, Irmay F, Magnin M, Morel P, Hoffmeyer P. Spontaneous anterior

    and lateral tibial compartment syndrome in type 1 diabetic patient: case report.J Trauma 1997;43:140-1.

    2. Smith AL, Laing PW. Spontaneous compartment syndrome in Type 1 diabetes mel-litus. Diabet Med 1999;16:168-9.

    3. Lecky B. Acute bilateral anterior tibial compartment syndrome after caesarian sec-tion in a diabetic. J Neurol Neurosurg Psychiatry 1980;43:88-90.

    4. Parmoukian VN, Rubino F, Iraci JC. Review and case report of idiopathic lowerextremity compartment syndrome and its treatment in diabetic patients. DiabetesMetab 2000;26:489-92.

    5. Hsu SI, Thadhani RI, Daniels GH. Acute compartment syndrome in a hypothyroidpatient. Thyroid 1995;5:305-8.

    6. Paletta CE, Lynch R, Knutsen AP. Rhabdomyolysis and lower extremity compart-ment syndrome due to influenza B virus. Ann Plast Surg 1993;30:272-3.

    7. Veeragandham RS, Paz IB, Nadeemanee A. Compartment syndrome of the legsecondary to leukemic infiltration: a case report and review of literature. J Surg Oncol1994;55:198-200.

    8. Sweeney HE, OBrien F. Bilateral anterior tibial compartment syndrome in associa-tion with nephrotic syndrome: report of a case. Arch Intern Med 1965;116:487-90.

    9. Hasaniya N, Katzen JT. Acute compartment syndrome of both lower legs caused byruptured tibial artery aneurysm in a patient with polyarteris nodosa: a case report andreview of literature. J Vasc Surg 1993;18:295-8.

    10. Griffiths D, Jones DH. Spontaneous compartment syndrome in a patient on long-

    term anticoagulation. J Hand Surg [Br] 1993;18:41-2.11. Ward WG, Eckardt JJ. Ganglion cyst of the proximal tibiofibular joint causing ante-

    rior compartment syndrome. J Bone Joint Surg [Am] 1994;76-A:1561-4.

    12. Ciacci G, Federico A, Giannini F, et al. Exercise-induced bilateral anterior tibialcompartment syndrome without pain. Ital J Neurol Sci 1986;7:377-80.

    13. Coley S, Situnayaki RD, Allen MJ. Compartment syndrome, stiff joints, and dia-betic cheiroarthropathy. Ann Rheum Dis 1993;52:840.

    14. Chester CS, Banker BWQ. Focal infarction of muscle in diabetics. Diabetic Care1986;9:623-30.

    15. Grigoriadis E, Fam AG, Starok M, Ang LC. Skeletal muscle infarction in diabetesmellitus. J Rheum 2000;27:1063-8.

    16. Lauro GR, Kissel JT, Simon SR. Idiopathic muscular infarction in a diabetic patient.J Bone Joint Surg [Am] 1991;73-A:301-4.

    17. Banker BQ, Chester CS. Infarction of the thigh muscle in the diabetic patient. Neu-rology 1973;23:667-77.