CASE REPORT

Anterior Tibial Compartment Syndrome Following Use of MAST Suit

Bruce E. Johnson, MD Spokane, Washington

A case of anterior tibial compartment syndrome following the use of the mili- tary antishock trousers (MAST) suit is reported. Early recognition of this com- plication is necessary to ensure a good outcome. Monitoring of the MAST pressure and use of the lowest pressure that is effective may decrease the likelihood of this complication. Johnson BE: Anterior tibial compartment syn- drome following use of the MAST suit. Ann Emerg Med 10:209-210, April 1981. military antishock trousers, complications

INTRODUCTION

While anterior tibial compartment syndrome has been cited as a complica- tion of local t rauma and tibial fractures'- and as a complication of revasculariza- tion surgery, 2 there has been no report to date of compartment syndromes re- lated to use of the mil i tary antishock trousers (MAST) suit. We report the case of a patient who had multiple complicating problems, including prolonged hypo- tension and renal failure, but whose compartment syndrome was most likely due to ischemia produced by the MAST suit.

CASE REPORT

A 21-year-old man was involved in a motorcycle accident and was subse- quently transported to the emergency department, arriving 20 minutes follow- ing the accident. At that time he complained of mild abdominal pain. There was no history of unconsciousness. Physical examination revealed a blood pressure of 60/40 mm Hg and a pulse rate of 130 beats/min. He was cool and diaphoretic. The head and neck were normal. The chest was clear to auscultation. The abdo- men was tender in the right upper quadrant; bowel sounds were absent. The extremity and neurologic examinations were normal.

A chest film showed fractures of the right seventh, eighth, and ninth ribs. The lungs were clear. Abdominal films showed a fracture of the left 12th rib and an undisptaced fracture involving the pubic symphysis. The hematocrit was 31.3%; the hemoglobin, 11.1 gm; and the WBC, 4,600/mm 3. A catheterized urine was normal.

Intravenous infusions of Ringer's lactate were started in both arms and allowed to run at maximum rates. A Foley catheter was placed and the urine was clear. A nasogastric tube was placed into the stomach and returns were clear. A mil i tary antishock trousers (MAST) suit was applied with both leg and abdominal portions inflated. The blood pressure rose to 90/60 mm Hg. O nega- tive blood was started, and shortly thereafter type-specific blood was begun. The patient 's abdomen became distended.

Because of persistent shock and abdominal pain and tenderness, the patient was taken to the operating room 30 minutes after admission for an exploratory laparotomy.

From the Deaconess Hospital Emergency Department, Spokane, Washington. Address for reprints: Bruce E. Johnson, MD, Deaconess Hospital Emergency Department, West 800 Fifth Avenue, Spokane, Washington 99210.

10:4 (April) 1981 Ann Emerg Med 209/61

The abdominal portion of the MAST suit was deflated but the leg portions were kept inflated while an exploratory laparotomy was done. The laparotomy revealed a ruptured right lobe of the liver, an avulsed right kidney, and a laceration of the vena cava. The patient underwent a right hepatic lobectomy, right ne- phrectomy, and suture repair of the vena cava. He remained in shock with a systolic pressure between 60 mm Hg and 80 mm Hg during the procedure. The leg portions of the MAST suit remained inflated for three and a half hours. He received 26 units of whole blood, six units of fresh frozen plasma, and three plate- let packs during the procedure.

Postoperatively the patient was anuric and developed adult respi- ratory distress syndrome and was maintained on a respirator. Mannitol and furosemide were given without improvement in renal status. The serum creatinine and BUN contin- ued to rise, and he subsequently un- derwent hemodialysis beginning on the fourth postoperative day.

Twelve hours postoperatively the patient complained of numbness in his feet and legs. This was observed but symptoms increased over the next two days. On the third postop- erative day, he underwent bilateral fasciotomies for anterior tibial com- partment syndromes. At the time of fasciotomy, the muscles swelled out but appeared to be viable. Several days later some of the muscle tissue was nonviable and was debrided.

Eventually the entire anterior compartment was resected because of necrosis. A delayed closure was even- tually done and this went on to heal

uneventfully. The respiratory dis- tress syndrome cleared after several days and the renal failure resolved after 56 days on hemodialysis. No significant abdominal complications occurred. At the time of discharge the pat ient was walking without crutches but with Ortholean pos- terior splints and he had a limp. It was thought that the patient might require further surgery in the future to correct dropped foot deformity.

DISCUSSION Anter ior t ibial compar tmen t

syndrome is a well-known complica- tion of local trauma and tibial frac- tures. 1 It is also a complication of re- vascularization surgery, where there has been a period ofischemia prior to revascularization. Coupland reported five patients who developed anterior compar tment syndrome following restoration of arterial flow in ische- mic limbs. These pat ients all re- quired decompression. 2 There have been no previous reports of compart- ment syndromes related to the use of the MAST suit.

Our patient had multiple com- plicating problems, including pro- longed hypotension and renal fail- ure, but the etiology of the compart- men t syndrome was most l ikely ischemia produced by the use of the MAST suit. The MAST suit was used on our patient for three and a half hours. The pressure in the suit was not monitored. There is a pop-off valve set at 104 mm Hg. In retro- spect, the pressure used in the MAST suit was estimated to be between 60 mm Hg and 90 mm Hg. The patient's systolic pressure during this period

ranged from 60 mm Hg to 80 mm Hg.

CONCLUSION Anter ior t ibial compar tmen t

syndrome may be a complication of the use of the MAST suit. Early di- agnosis and treatment of this condi- tion are mandatory for successful re- sults. Following prolonged use of the MAST suit, any patient complaining of leg pain should be carefully eval- uated. Monitoring the MAST suit pressure and use of the lowest pres- sure that is effective in treating the patient's shock would seemingly re- duce the incidence of this complica- tion. MAST suit pressures of 20 mm Hg to 30 mm Hg will return most of the venous blood in the legs to the central circulation. MAST suit pres- sures at or above the patient's sys- tolic pressure will produce ischemia and should not be used unless clini- cal benefit results.

REFERENCES

1. Holden CE: Compartmental syn- dromes following trauma. Clin Orthop 113:95-102, 1975. 2. Coupland GA: Anterior tibial syn- drome following restoration of arterial flow. Aust NZ J Surg 41:338-341, 1972. 3. Patman RD: Compartmental syn- dromes in peripheral vascular surgery. Clin Orthop 113:103-110, 1975. 4. Rorabeck CH: The pathophysiology of the anterior tibial compartmental syn- drome. Clin Orthop 113:52-57, 1975. 5. Tintinalli JE: Tibial compartment syn- drome. JACEP 6:506-509, 1977. 6. Masten FA, Krugmire RB Jr: Com- partmental syndromes. Surg Gynecol Ob- stet 147:943-949, 1978.

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