CC = RLE pain

HPI

• 54 year old male with history of metastatic prostate cancer and recently diagnosed R popliteal DVT on Eliquis presents with RLE pain
• 4 hours prior to arrival, sudden onset severe, sharp, stabbing anterior R leg pain that is worse with palpation and movement 
• Rapid onset let swelling over the past 4 hours
• Denies paresthesias, weakness

Physical Exam

Vital Signs: BP=115/75, HR=124, T= 97.9 °F, RR=20 , SpO2 100%

• General: uncomfortable appearing
• Cardiac: tachycardia, regular rhythm, no murmur
• Extremity: the RLE is swollen, tense, and there is severe pain to light touch and passive stretch of the muscles in the anterior compartment
• Pedal pulse present by doppler
• No weakness, numbness in the RLE

Ddx

• Occlusive DVT causing arterial insufficiency
• Acute arterial thomboembolism leading to acute limb ischemia
• Compartment syndrome

Management 

• heparin drip due to concern of compartment setting due to DVT
• Consulted general surgery for compartment syndrome
• Patient was taken level 1 to the OR for 4 compartment fasciotomy of the RLE

Pearls:

• The most sensitive and earliest finding of compartment syndrome is severe pain with passive or active stretching of the muscles in the compartment
• This occurs before prolonged ischemia causes the classic pallor, pulselessness, paresthesias, and paralysis
• Most cases are in the setting of trauma, but compartment syndrome can also occur due to hemophilia or rhabdomyolysis
• There are several case reports of compartment syndrome in the setting of occlusive DVT of the lower extremity due to impaired venous outflow and resulting edema and ultimately increased compartment pressure
• 40% of compartment syndromes occur in the lower leg, where there are four compartments: anterior, lateral, superficial posterior, superficial posterior
• Compartment syndrome should be treated immediately with fasciotomy; muscle and nerve injury is initially reversible, but after approximately 8h will become irreversible
• Consult surgery immediately for any patient with a clinical suspicion for compartment syndrome: early surgery is key to preventing irreversible damage

References

Beck MA, Heller P. “Compartment Syndrome.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (1876-1879). 2020 Newman PA, Deo S. Non-traumatic compartment syndrome secondary to deep vein thrombosis and anticoagulation.

BMJ Case Rep. 2014;2014:bcr2013201689. Published 2014 Jan 17. doi:10.1136/bcr-2013-201689 Abdul W, Hickey B, Wilson C. Lower extremity compartment syndrome in the setting of iliofemoral deep vein thrombosis, phlegmasia cerulea dolens and factor VII deficiency. BMJ Case Rep. 2016;2016:bcr2016215078. Published 2016 Apr 25. doi:10.1136/bcr-2016-215078