Interesting case....any ideas?

[OLauraLee]

Just saw a 40 year old male presenting with a referral for a right calf strain. Stated that he was on a field exercise and ran down a hill and heard a snap in his right lower leg. He rested the leg for a week, but then began having increased swelling. Seen by a doctor and referred to us.
Today he presented with entire lower leg swelling, pitting edema, cool foot and ankle, and unable to feel the pulse. Sent him for investigations to rule out a DVT and this was clear. Just wondering if anyone else has any other ideas as I haven't seen one like this before.

[Bas Asselbergs]

Compartment syndrome as a result of a muscle tear. Lots of bleeding deep inside the bundles restricting return flow.

When they do a Doppler for DVT, the technicians usually (at least here in town) look for reduced lumen of bloodvessels in addition to outright blockages. If that was done, then my diff Dx is not likely.

[OLauraLee]

Thanks very much for that. Makes a lot of sense. Will discuss with he doctor.

[Diane]

Stress fracture should be ruled out.

[OLauraLee]

XRays were clear. Spoke with doctor about having acute compartment syndrome investigated. Will see.

[smikolic]

How soon following injury were the x-rays taken?
As I am familiar, x-rays are only reliable for ruling out a stress fx if taken >3 days post injury, otherwise a bone scan or US are more reliable.....I think.

[OLauraLee]

The XRay was 7 days after. The doctor has also ordered an MRI with this case.

[Frédéric]

If the above pathologies are ruled out, could be a sympathetic dysregulation secondary to a direct trauma to the tibial or sural nerve or secondary to ischemia on the nerves following the initial oedema following a muscle strain. Some form of early CRPS.

Compartement syndrome often evolve pretty rapidly and can have dramatic implications. It seems unlikely this was missed until now.

[joebrence9]

How soon following injury were the x-rays taken?
As I am familiar, x-rays are only reliable for ruling out a stress fx if taken >3 days post injury, otherwise a bone scan or US are more reliable.....I think.

Correct. Could do a poor-man's stress fracture test and use a vibrating tuning fork along the tibia and see if it lights them up. I have also read an article which looked at tapping of the bone and listening to the tapping through a stethascope. If the tapping becomes muffled or disappears, it could warrant a bone scan.

I would be concerned about compartment syndrome too and would call the doc to have a pressure test done. The signs do sound quite concerning (entire LE swelling, pitting edema, cool foot) and likely something that needs further diagnostic tests.

[John W]

FYI: There's a good diagnostic clinical prediction rule for determining whether to refer out for further testing for DVT by Wells et al, which can be found here.

[OLauraLee]

Thanks everyone. All very helpful. The first thing I checked were the clinical prediction rules by Wells et al. Very helpful and he scored 3, which warranted a doppler investigation (which was negative). Although, it did show a hematoma in the muscle belly.
After reading Bas' reply I spoke to one of the docs about the compartment syndrome and they called the orthopaedic surgeon who didn't think it was likely, but they'd check it out for us. I refused to see this patient until he was cleared of any medical emergency. So, waiting to see if compartment syndrome gets ruled out.


"Compartement syndrome often evolve pretty rapidly and can have dramatic implications. It seems unlikely this was missed until now" This is usually the case, but this person stayed away from medical attention for 7 days because he didn't want to fail a course he was on.

[Jon Newman]

Was he taking any medication during that seven days?

[OLauraLee]

He was taking Naproxen during that time and still takes it now.

The doctor didn't go ahead with the compartment testing afterall. The reason he gave the patient was that he didn't have enough pain for it to be compartment syndrome. He had blood and urine tests done and was told to see us for exercises. MRI is booked for Sept 1. And, he's flying to BC from Atlantic Canada tomorrow. He was cleared to do this but I'm very concerned for this patient.

Will let everyone know how this one turns out.

[joebrence9]

didn't go ahead with the compartment testing afterall. The reason he gave the patient was that he didn't have enough pain for it to be compartment syndrome

Very interesting....I like the confidence of this doc (note sarcasm)...I wonder what this doc knows about pain??? OLauraLee, the discussion of pain is quite prevelant here but fyi, the degree of injury is not indicitive of the degree of pain.

[Erica]

Wow, he was cleared to fly, really? I know DVT was ruled out but not sure I would feel confident in having him fly. I would echo Frederic in his response-could be the beginnings of some early CRPS. I had a patient a couple of years ago who was a police officer, injured while chasing a suspect on the beach, his symptoms started almost exactly like your patient's. I did not see him at that time-I caught him after the poor guy had been to every MD, PT known to man. He still had the color changes, (he was upper extremity), and temperature changes and the presentation you see with the chronic CRPS patients. He eventually got better but it was not a easy case to manage I have to say. Good luck and keep us posted.
Erica

[Bas Asselbergs]

Agree with the CRPS possibility.
The hematoma finding on the Doppler may be an indicator that there may have been a slow seep swelling to full compartment syndrome - has happened before with a couple of cases (over the last 28 years....).

Yeah - flying?!? Wow.

[Jon Newman]

It's possible his injury/NSAID use could explain his edema. He doesn't have much pain? I'm surprised he's in PT.

Explanations for coagulation activation after air travel.
Journal of Thrombosis & Haemostasis. 8(5):971-8, 2010 May.
Schreijer, A J M. Hoylaerts, M F. Meijers, J C M. Lijnen, H R. Middeldorp, S. Buller, H R. Reitsma, P H. Rosendaal, F R. Cannegieter, S C.

SUMMARY BACKGROUND: It is unknown whether venous thrombosis after long haul air travel is exclusively attributable to immobilization.
OBJECTIVES: We determined whether the following mechanisms were involved: hypoxia, stress, inflammation or viral infection.
PATIENTS/METHODS: In a case crossover setting in 71 healthy volunteers who were exposed to an 8-h flight, 8-h movie marathon and 8 h of regular activities, we compared markers for several hypothetical pathways: plasminogen activator inhibitor-1 (PAI-1), stress, plasma factor (F)VIII coagulant activity (FVIIIc), soluble P-selectine (sP-selectine), interleukin-8 (IL-8) and neutrophil elastase. We reported earlier an activated clotting system, as evidenced by thrombin generation, in 17% of volunteers after the flight.
RESULTS: PAI-1 increased by 4.2 ng mL(-1) (CI95:-49.5 to 6.5) in volunteers with an activated clotting system whereas it decreased in those without (-20.0 ng mL(-1), CI95:-33.2 to -14.0). FVIIIc levels rose more in individuals with clotting activation (18.0%, CI95:-1.0 to 33.0) than in those without (2.0%, CI95:-2.0 to 5.0). The increases in FVIIIc were not associated with stress, which appeared unrelated to clotting activation. sP-selectin increased in those with clotting activation (3.5 microg L(-1), CI95: -3.0 to 10.0), but decreased in those without (-0.5 microg L(-1), CI95: -2.0 to 2.0). Changes in levels of neutrophil elastase or IL-8 were not different between the subjects with and without clotting activation.
CONCLUSIONS: Our results do not support the hypotheses that stress, infection or air pollution are involved in the development of a prothrombotic state in air travellers. After long haul air travel, this state is more pronounced in patients with risk factors and may be caused by hypoxia, triggering systemic inflammation and platelet activation, leading to coagulation induction and degranulation of platelets.

What are his risk factors for developing VTE?

[OLauraLee]

Thanks everyone so much for the feedback. It feels really good to hear everyone's ideas and is a great learning experience. I love it.

The doctor's comment about "not enough pain". He's a new grad and has a lot to learn. I thought the patient's pain was very realistic considering he could not weight bear and had a great loss of knee and ankle ROM associated with pain and tightness. Regardless, I know that hurt does not equal harm and vice versa. Maybe another inservice for our docs is in order.

The CRPS is looking quite reasonable as well, especially at reading about your patient Erica. Does anyone know how long it takes for it to develop? I did some reading more this evening and all it really talked about was acute, sub-acute and chronic.

And thanks for the abstract John. I thought his risk factors would be the uncontrolled swelling, poor circulation, and immobilization for several hours. I'll be really anxious to hear how he makes out. I never thought for a second they'd let him fly right now.

[handson]

has he had any manual lymph drainage to decrease the swelling at least? go to the find a therapist link on the dr. vodder international website to see if there's a trained therapist near you. once the swelling is decreased you may be able to see much more, and a trained mld therapist can have the swelling down in a few treatments.