A rare cause of acute compartment syndrome in the thigh: a c
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Acute compartment syndrome (ACS) is an orthopedic emergency that requires urgent fasciotomy and decompression to avoid significant morbidity. It is most commonly caused by a fracture or crush injury. This female patient in her 50s presented to the emergency department (ED) via ambulance. She has a past medical history of obesity and gastroesophageal reflux disease and is a non-smoker. She had slipped on the floor and landed on her left side. She was unable to get up from the floor due to significant pain in her left leg. Her husband found her 2 hours later and rang an ambulance. The paramedics administered significant amounts of analgesia during transit including intra-muscular Ketamine, Morphine, and inhaled Methoxyflurane.

Initial assessment by an ED doctor noted the patient keeping their left hip in a flexed position with a tense palpable hematoma in the posterior medial aspect of the left thigh. Noted that the patient was confused due to ketamine use and so could not ascertain if could actively move their toes or test for sensation in the foot. Capillary refill was less than 2 seconds distally with palpable pulses. The provisional diagnosis was a femoral shaft fracture. X-ray was taken and demonstrated no evidence of femoral fracture. The patient was re-reviewed with ongoing severe pain, paraesthesia in L5/S1 dermatomes and myotomes of the foot, and referred to orthopedics for urgent review.

An urgent computed tomography angiography of the affected side was performed, as it was unclear if the hematoma was in the posterior or medial compartment; this demonstrated a large hematoma in the posterior compartment, with no cause identified. CT angiography showed multiple hypertrophied branches of the left internal iliac artery with heavy collateralization to the territory of the occluded left common femoral artery. Pathological dilatation of the collateral branch of the left obturator artery was identified as the source of bleeding and embolized. A further source of bleeding from a collateral muscular branch of the internal iliac artery was also embolized. During this time the patient lost 4 liters of blood and so had multiple transfusions, she developed an acute kidney injury and was managed in the intensive care unit for 2 days.

A total of 3 days later, she had her thigh wound closed. She developed a postoperative non-infected seroma, which was drained. She has no sensation in L5/S1 dermatomes. Medical Research Council power scale 0/5 in L5 and S1 myotomes. She is able to mobilize with an ankle and foot orthosis to prevent her foot drop and will be followed up in the hope that function returns.