Acute Compartment Syndrome of the Leg Following Injury to Perforating Branch of Peroneal Artery After a Severe Ankle Sprain in a Pediatric Patient – A Case and a Review of Literature Marjan Raad1, Anoop Anugraha2

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Learning Point of the Article:

It is pertinent to be vigilant of acute compartment syndrome in cases of severe ankle sprain.


Case Report | Volume 10 | Issue 8 | JOCR November 2020 | Page  68-71 | Marjan Raad, Anoop Anugraha. DOI: 10.13107/jocr.2020.v10.i08.1864


Authors: Marjan Raad[1], Anoop Anugraha[2]

[1]Department of Trauma and Orthopaedics, Darent Valley Hospital, Dartford, Kent,

[2]Department of Orthopaedics, Southampton General Hospital, Southampton, UK.

Address of Correspondence:
Dr. Marjan Raad,
Department of Trauma and Orthopaedics, Darent Valley Hospital, Darent Wood Road, Dartford, DA2 8DA.
E-mail: marjan.raad@btinternet.com


Abstract

Introduction: Acute compartment syndrome (ACS) of the leg is seen most often following severe fractures, crush injuries, burns, tight casts, or dressings but rarely after ankle sprains. Very few cases have been found in the literature of compartment syndrome developing after ankle ligament disruptions. We report a case of ACS secondary to an ankle sprain in a 10-year-old child.
Case Report: A 10-year-old girl presents to the emergency department after jumping on an in-ground trampoline and slipping onto the surrounding grass and twisting her right ankle. This was followed by immediate swelling of her ankle. In the emergency department, her examination was notable for compartment syndrome. Although there was significant swelling around the ankle, she had good pulses in dorsalis pedis and posterior tibial vessels and normal sensations in her foot. A radiograph demonstrated an undisplaced fracture of medial malleolus with possible disruption of lateral ligament complex of the ankle. The patient was admitted, and the leg became more swollen the following morning with significant increase in pain levels and foot turned cold and purple with weak pulses. She had a delayed capillary refill time and reduced sensation in common peroneal nerve distribution over lateral aspect of foot and tense anterior and lateral compartments of the leg. Therefore, she was taken to theater and a standard open fasciotomy of the leg was performed through a longitudinal incision on the lateral side of leg and compartments decompressed. Fasciotomy revealed a large hematoma in the leg extending into the ankle joint and an avulsed perforating branch of peroneal artery. Postoperatively pain improved, passive toe stretching was no longer painful and she was immobilized in a below-knee plaster cast.
Conclusion: ACS of leg is often associated with high-energy trauma and rarely seen after ankle injuries. To the best of our knowledge, this is the first reported case of compartment syndrome developing in a pediatric patient following inversion sprain of ankle, leading to rupture of perforating peroneal vessel in the leg.
Keywords: Compartment syndrome, ankle sprain.


Introduction
Acute compartment syndrome (ACS) of the leg is a well-known complication following severe fractures, crush injuries, burns, or tight casts, yet it remains difficult to diagnose and the only effective treatment is surgical fasciotomy [1]. Very few cases have been found in the literature of compartment syndrome developing after ankle ligament disruptions. The current diagnosis of ACS is based on clinical findings and intramuscular pressure (IMP) measurement [1]. We report a case of ACS secondary to an ankle sprain in a 10-year-old child.

Case Report
A 10-year-old girl presents to the emergency department after jumping on an in-ground trampoline and slipping onto the surrounding grass and twisting her right ankle. This was followed by immediate swelling over the lateral aspect of her ankle of approximately 3×4 cm. She presented immediately to the emergency department and her examination was notable for compartment syndrome. Although there was significant swelling around the ankle, she had good pulses in dorsalis pedis and posterior tibial vessels and normal sensations in her foot. A radiograph demonstrated an undisplaced fracture of medial malleolus with possible disruption of lateral ligament complex of the ankle (Fig. 1, 2). She was admitted overnight for observation, elevation, and pain relief. The following morning, the swelling was now circumferential around the ankle and the lower leg, with significant increase in pain levels and foot turned cold and purple with weak pulses. She had a delayed capillary refill time and reduced sensation in common peroneal nerve distribution over lateral aspect of foot and tense anterior and lateral compartments of the leg, these symptoms appeared approximately 20 h after the time of injury. She had no motor deficit preoperatively. Differential diagnosis at this time consisted of a high-grade ankle sprain, hematoma, and compartment syndrome. A formal diagnosis of compartment syndrome was made based on high clinical suspicion; the patient had neurovascular compromise, tense compartments, and pain on passive toe stretching. The patient then underwent an urgent fasciotomy approximately 24 h after time of injury. The radiographs had not shown proximal fibular fracture but examination under anesthetic showed ankle joint to be very unstable in varus and on anterior drawer testing suggesting disruption of the syndesmosis and lateral ligament complex. Compartmental pressure measurements showed 44 mmHg in anterior and 33 mmHg in lateral compartments (measured using Stryker intracompartmental pressure monitoring system), normal compartment pressures should be between 11 and 13 mmHg. A standard open fasciotomy of the leg was performed through an anterolateral longitudinal incision extending halfway between the crest of the tibia and the fibula and anterior and lateral compartments were decompressed. Once the intermuscular septum was incised, a large hematoma revealed itself in the anterolateral ankle extending around 10 cm above the ankle and an avulsed perforating branch of peroneal artery. The hematoma was evacuated, and the perforating peroneal artery was ligated. The anterior capsule of the ankle was avulsed with the anterior tibiofibular ligament (ATFL) and the calcaneofibular ligament (CFL), was completely disrupted. Peroneal muscles were dusky in appearance but pinked on fascial release. Anterior, deep, and superficial compartment muscles were healthy (Fig. 3). Postoperatively pain improved, passive toe stretching was no longer painful and she was immobilized in a below-knee plaster cast. Forty-eight hours postoperatively, she was taken to the operating room and her lateral ligament complex, that is, ATFL and CFL was repaired. Intraoperatively, syndesmosis felt grossly unstable and a single syndesmotic screw engaging four cortices was inserted to stabilize ankle mortise. Fasciotomy wound was closed without any skin grafts. Her 6-week follow-up showed normal sensations and motor power in the common peroneal distribution and a good recovery.

Discussion
ACS of the leg is seen most often following severe fractures, crush injuries, burns, tight casts, or dressings but rarely after ankle sprains. Very few cases have been found in the literature of compartment syndrome developing after ankle ligament disruptions. Cases have been reported in which compartment syndrome occurred in ankle injuries following rupture of the peroneus longus muscle and following vascular injuries to anterior tibial artery and perforating branch of peroneal artery, but we are unaware of this injury developing in a pediatric patient. The peroneal artery arises from the posterior tibial artery 2.5 cm below the lower border of popliteus muscle; it then passes obliquely, runs down the posteromedial surface of the fibula, and divides into the lateral calcaneal branches. The perforating branch pierces the interosseous membrane about 5 cm above the lateral malleolus and anastomoses with the anterior lateral malleolar vessels and passes down and supplies the tarsus. The vessel is susceptible to be torn on severe inversion sprains due to the fact it is tethered to the interosseous membrane [3] and continued active bleeding following a partial or complete tear can increase compartmental pressures in a tight space. Ward [2] reported a case of compartment syndrome of leg in a 23-year-old soldier following inversion sprain while playing basketball. This was explored and found to be due to avulsion of perforating branch of peroneal artery. Chen [3] reported a case of compartment syndrome developing in a 24-year-old following a vehicular accident riding a motorcycle sustaining severe inversion injury, again due to disruption of perforating peroneal vessel, Maguire et al. [4] in 1972 reported a case of traumatic aneurism of perforating peroneal artery following a plantar flexion and inversion sprain to ankle in a 19-year-old basketball player. He believes that proximal attenuation of anterior tibial artery and predominance of peroneal artery are seen in 3.5% of individuals and are bilateral in 40% of them. This artery is securely attached as it passes through interosseous membrane and its close proximity to head of talus, makes the vessel susceptible to stretching on inversion and plantar flexion strains leading to the development of a false aneurism. The injury leads to the development of a tense hematoma on lateral aspect of leg necessitating an exploration and ligature of traumatic aneurism of perforating peroneal artery. Case reports have been published by Cheng et al. [5], Gabisan et al. [6], and Stabaugh et al. [7] of lateral compartment syndrome of leg developing following avulsion of peroneus longus muscle. Dhawan et al. [8] reported inversion sprain of ankle tearing anterior tibial artery causing compartment syndrome of foot. Maurel et al. [9] and Creighton et al. [10] reported cases of compartment syndrome of foot developing after inversion sprains of ankle where a definite cause was not identified.

Conclusion
ACS of leg is often associated with high-energy trauma and rarely seen after ankle injuries. To the best of our knowledge, this is the first reported case of compartment syndrome developing in a pediatric patient following inversion sprain of ankle, leading to rupture of perforating peroneal vessel in the leg. The aim of this report is to highlight the possibility of compartment syndrome occurring after low-velocity soft-tissue trauma where compartment syndrome was confined to two compartments. A high index of suspicion is needed for a timely diagnosis and to avoid the potential of morbidity following a compartment syndrome and its consequences. The major complication of a compartment syndrome is a missed diagnosis, which can lead to tissue necrosis, neurovascular compromise, contractures, and decreased limb function [11].

Clinical Message
ACS rarely occurs after a low-velocity injury. Urgent fasciotomy and exploration are pertinent in patients of whom compartment syndrome is suspected. Intercompartmental pressures can aid diagnosis. High index of suspicion is needed for a timely diagnosis to avoid the potential of morbidity and the sequelae of compartment syndrome. To the best of our knowledge, this is the first reported case of compartment syndrome developing in a pediatric patient following inversion sprain of ankle, leading to rupture of perforating peroneal vessel in the leg.

References
1. Schmidt AH. Acute compartment syndrome. Injury 2017;48 Suppl 1:S22-5.
2. Ward NJ, Wilde GP, Jackson WF, Walker N. Compartment syndrome following ankle sprain. J Bone Joint Surg Br 2007;89:953-5.
3. Chen YP, Ho WP, Wong PK. Acute compartment syndrome secondary to disruption of the perforating branch of the peroneal artery following an acute inversion injury to the ankle. Int J Surg Case Rep 2014;5:1275-7.
4. Maguire DW, Huffer JM, Ahlstrand RA, Crummy AB Jr. Traumatic aneurysm of perforating peroneal artery. Arterial bleeding-cause of severe pain following inversion, plantar flexion, Ankle sprains. J Bone Joint Surg Am 1972;54:409-12.
5. Cheng LY, Niedfeldt NW, Lachacz J, Raasch WG. Acute, isolated lateral compartment syndrome after ankle inversion injury. Clin J Sport Med 2007;17:151-2.
6. Gabisan GG, Gentile DR. Acute peroneal compartment syndrome following ankle inversion injury: A case report. Am J Sports Med 2004;32:1059-61.
7. Slabaugh M, Oldham J, Krause J. Acute isolated lateral leg compartment syndrome following a peroneus longus muscle tear. Orthopedics 2008;31:272.
8. Dhawan A, Doukas WC. Acute compartment syndrome of the foot following an inversion injury of the ankle with disruption of the anterior tibial artery. A case report. J Bone Joint Surg Am 2003;85:528-32.
9. Maurel B, Brilhault J, Martinez R, Lermusiaux P. Compartment syndrome with foot ischemia after inversion injury of the ankle. J Vasc Surg 2007;46:369-71.
10. Creighton RA, Kinder J, Bach BR. Compartment syndrome following recurrent ankle inversion injury. Orthopedics 2005;28:703-5.
11. Gresh M. Compartment syndrome in the pediatric patient. Pediatr Rev 2017;38:560-5.


Dr. Marjan Raad Dr. Anoop Anugraha 

How to Cite This Article: Raad M, Anugraha A. Acute Compartment Syndrome of the Leg Following Injury to Perforating Branch of Peroneal Artery After a Severe Ankle Sprain in a Pediatric Patient – A Case and a Review of Literature. Journal of Orthopaedic Case Reports 2020 November;10(8): 68-71.

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