Delayed Onset Acute Compartment Syndrome in Patient on Blood Thinning Medications: Surgical Management Utilizing Regenerative Collagen Technologies and Modular External Fixation Following a Traumatic Foot and Ankle Injury
Because acute compartment syndrome (ACS) is most commonly associated with traumatic bone fractures in young men, identifying ACS in the absence of fracture can be challenging and lead to delay in care.1 JS is a middle-aged male with a past medical history including epilepsy and a cerebral vascular accident with residual left-sided weakness, treated with ongoing anticoagulation and anticonvulsant therapies. After a fall in the shower, JS was immediately seen at a medical facility but was released from care and instructed to seek further care if the injury worsened. Two days later, JS presented to his local Emergency Department complaining of worsening swelling and pain to his right ankle. Podiatric Medicine and Surgery service was notified. Physical examination revealed firm dorsal and lateral compartments of the right foot with significant pain and edema; signs and symptoms of increased interstitial and compartmental pressures. Pedal pulses were present but a lateral compartment pressure measurement of 43mmHg was noted. Emergent fasciotomies of the right foot were performed. Extensive sharp debridement of necrotic and non-viable tissue was required to mitigate soft tissue damage. Appreciable damage to the lateral dorsal cutaneous nerve was noted; a collagen nerve wrap was placed to isolate and protect the mangled nerve. A bilayered skin substitute was placed to facilitate dermal regeneration in preparation for a staged rotational flap procedure. Four weeks later, following dermis regeneration, a rotational dorsal flap procedure was done and an external fixator device was applied for preservation of the reconstructive repair. The soft tissue wound completely healed at five months following the flap procedure. Full function of the patient’s foot and ankle was restored and the patient returned to work. ACS without fracture typically occurs in older patients with more comorbidities. Anticoagulation should be considered a significant risk factor for these scenarios.