Atraumatic peroneal compartment syndrome: An uncommon entity

Abstract

Peroneus longus ruptures are less common than ruptures of the peroneus brevis muscle and are seldom described in the literature. Ankle inversion injuries causing injury to the distal end of the peroneus longus muscle resulting in lateral compartment syndrome have been documented in the literature. We are presenting an unusual case of peroneal compartment syndrome with no overt ankle injury. The athlete was able to continue physical activity for a week before seeking medical attention. This case necessitates careful attention in assessing non-contact injuries in cases with possible lateral compartment syndrome.

Introduction

Compartment syndrome represents elevated pressure within a closed fascial space, resulting in decreased capillary perfusion threatening tissue viability. Compartment syndrome is often noticed in patients with lower extremity fractures or blunt trauma. Atypical and delayed presentation of trivial trauma presenting as chronic compartment syndrome poses a great challenge for treating surgeons in early diagnosis and intervention to prevent devastating complications. It is well documented in the literature that rupture of the distal peroneus longus muscle may present as lateral compartment syndrome as a surgical emergency. These injuries seek medical attention in view of severe pain difficulty in using the ankle following twisting injuries. This article presents a case of lateral compartment syndrome of the leg secondary to proximal peroneus longus muscle rupture in an athletic male who continued strenuous activity after sustaining the injury, indicating an acute injury precipitating chronic compartment syndrome.

Case report

A 33-year-old well-built athletic male patient presented to the general surgery outpatient department with complaints of pain in the lateral aspect of his right leg for seven days. He admitted a history of strenuous activity over the last 10 days, including long marathon running for 42 km, followed by participation in uphill cycling, and a recent history of participation in football activities. He had mild discomfort in the lateral aspect of his leg, which he ignored during the marathon and continued to participate in other sports activities of strenuous nature. He then experienced sharp shooting pain in the lateral aspect of his right leg for the past two days when he tried to do sharp cutting of the football while playing.

Being a trained athlete, he applied ice packs and took some analgesics before he reported to the hospital. On arrival at the hospital, he was in distress with a limping gait. On examination, his vitals were stable, and the lateral aspect of his right leg was tender, tense, and firm. Plantar flexion was painless, whereas inversion and eversion of the foot were painful with a dorsiflexion of 2/5. Examination of distal pulses including the dorsalis pedis and anterior and posterior tibial arteries was normal. Distal capillary refill was less than 2 s. There was a loss of fine touch sensation over the shin and dorsum of the feet. An immediate ultrasound was ordered, which excluded deep venous thrombosis and revealed muscle edema in the lateral compartment of the right leg.

In view of lateral compartment syndrome clinically, he was taken up for an emergency fasciotomy on the same day. The patient underwent fasciotomies involving the release of both anterior and lateral compartments. Anterior compartment muscles were found to be healthy. The lateral compartment revealed a complete tear of the peroneus longus belly proximally, around 5 cm below the fibular head. Around 60–70% of the peroneal musculature was dark, friable, and nonreactive to electrocautery stimulation (Fig. 1). A minimal hematoma was evacuated, and nonviable tissues were debrided until fresh bleeding commenced. The anterior compartment was then released, which revealed viable musculature. Post-operatively, the limb was stabilized with a posterior splint. He recovered from pain immediately postsurgery, and a foot drop was noticed. He was taken again for debridement on days two and four, for irrigation and debridement. Later, split skin grafting for the raw area with wound closure was done on postoperative day 5 (Fig. 1). Postoperatively, the limb was immobilized for a period of 7 days, followed by rigorous physiotherapy involving active and passive exercises of the leg. Presently, he is undergoing physiotherapy with controlled, supervised ankle motion exercises and manual resistance training, with good signs of recovery and improvement in dorsiflexion of the foot to 4/5. Informed patient consent was obtained for use of data and images for publication purpose.

Fig. 1.

(A) Preoperative image showing the swollen right leg; (B) Intraoperative image showing rapture and necrosed peroneus longus tendon proximally; (C) Intraoperative image of split thickness skin graft in raw area; (D) POD % showing good uptake. POD, postoperative day.

Discussion

Peroneus longus is a long muscle situated in the lateral compartment of the leg, together with the peroneus brevis muscle. Peroneus longus takes its origin from the proximal aspect of the fibula and attaches to the medial cuneiform and the first metatarsal bone.^1,2 Eversion and plantar flexion of the ankle are performed by the lateral compartment of the leg. Injuries involving the ankle, especially twisting in nature, result in distal peroneal longus muscle rupture and have been described in the literature.² Injuries sustained during non-contact sports activities resulting in proximal peroneus longus muscle rupture are seldom seen.³

Ebenezer et al. also described the atypical presentations of compartment syndrome which are difficult to pick up early and the delay in diagnosis.⁴ These injuries need careful vigilance of clinicians for early intervention. In injuries causing distal peroneus longus muscle rupture, a twisting injury to the ankle is the predominant cause, as in our case. Resultant muscle edema with hemorrhage raised the compartmental pressure over time in our case, which explains the delayed presentation.⁵ Due to compression over the peroneal nerve, neuropraxia was imminent, which presented as intermittent foot drop.⁶ The long-term outcome in our case showed promising results with good recovery in terms of both sensory and motor function. The outcome is directly attributed to early intervention, as described by Jimenez et al.⁷ An athlete with a similar injury could return to his sports activities in two months’ time as described by Rehman et al.⁸

Conclusion

Late diagnosis and delayed intervention in a case of compartment syndrome are devastating and may result in the loss of a limb. Having a high index of suspicion and taking a detailed history of the pattern of injury and progression over time with careful clinical examination is critical for prompt diagnosis. The author further insists not to wait for clinical signs to appear and recommends early intervention, even for innocuous injuries.

Patients/ Guardians/ Participants consent

Patients informed consent was obtained.

Ethical clearance

Not Applicable.

Source of support

Nil.

Disclosure of competing interest

The authors have none to declare.