rev bras ortop.2018;53(2):244–247
SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Case Report
Segmental decompressive fasciotomy for acute non-traumatic compartment syndrome in a professional soccer player: case report 夽
Daniel Baumfeld
a,b,∗, André Lourenc¸o Pereira
c, Claudio Freitas Guerra Lage
b, Gabriel Mendes Miura
b,d, Yuri Vinicius Teles Gomes
a, Caio Nery
eaUniversidadeFederaldeMinasGerais,BeloHorizonte,MG,Brazil
bDepartamentoMédico,CruzeiroEsporteClube,BeloHorizonte,MG,Brazil
cHospitaldasClínicas,UniversidadeFederaldeMinasGerais,BeloHorizonte,MG,Brazil
dHospitalBiocor,BeloHorizonte,MG,Brazil
eDepartamentodeOrtopediaeTraumatologia,UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil
a r t i c l e i n f o
Articlehistory:
Received28November2016 Accepted23February2017 Availableonline15February2018
Keywords:
Lessinvasivesurgicalprocedures Fascia/surgery
Compartmentsyndromes Surgicaldecompression Soccer
Athletes
a bs t r a c t
Acutecompartmentsyndromeinathletesisarareorthopedicemergencyassociatedwith strenuousexercise.Itisoftendiagnosedlateandcanleadtoseverecomplicationsand highmorbidity.Thisreportdescribesthecaseofayoungsoccerplayerwithacutecompart- mentsyndromewithnohistoryoftrauma,diagnosedandtreated24haftertheonsetof symptoms,throughminimallyinvasivedecompressivefasciotomy,withgoodpostoperative evolution.
©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Síndromecompartimentalagudanãotraumáticaematletadefutebol tratadaporfasciotomiadescompressivasegmentar:relatodecaso
Palavras-chave:
Procedimentoscirúrgicosnão convencionais
Fascia/cirurgia
r e su m o
A síndrome de compartimento aguda não traumática em atletas é uma emergência ortopédicararaassociadaaoexercíciofísicoextenuante.Apresentadiagnósticodifícil,fre- quentementetardio,podelevaracomplicac¸õesgravesealtamorbidade.Osautoresrelatam
夽StudyconductedatDepartamentoMédicodoCruzeiroEsporteClube,UniversidadeFederaldeMinasGerais,BeloHorizonte,MG,Brazil.
∗ Correspondingauthor.
E-mail:danielbaumfeld@gmail.com(D.Baumfeld).
https://doi.org/10.1016/j.rboe.2018.02.001
2255-4971/©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle undertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
rev bras ortop.2018;53(2):244–247
245
Síndromescompartimentais Descompressãocirúrgica Futebol
Atletas
ocasodeumaatletadefuteboljuvenilcomumasíndromecompartimentalagudasem históriadetrauma,diagnosticadaetratada24horasapósiníciodossintomas,atravésde fasciotomiadescompressivaminimamenteinvasiva,comboaevoluc¸ãopós-operatória.
©2017SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Acute leg compartment syndrome after physical exertion inathletes isan unusualorthopedicemergency caused by strenuousphysicalexercisethatleadstomuscleedemaand stiffnessofthefascia,progressingtoanoxia,ischemia,and muscle necrosis. Its diagnosis is difficult, requiring a high indexofsuspicion,especiallyinabsenceofassociatedtrauma or fracture. If decompressive fasciotomy is not performed rapidly,complicationssuchasischemiccontraction,neuro- logicaldeficit,infection,andmusclenecrosiscanoccurand definitelyimpairtheathlete’scareer.Inthepresentstudy,the authorsdescribetherarecaseofa16-year-oldsoccerplayer who presentedacute left legcompartmentsyndrome after exhaustivetraining,withoutassociatedtrauma;thediagnosis waslate,andthepatientwastreatedbyminimallyinvasive surgery,presentinggoodpostoperativeevolution.
Case report
A16-year-oldmalesoccerplayerwithnocomorbidities,pre- viously asymptomatic, had performed an intense practice sessionfor90min,withnohistoryoftraumaorcomplaints duringhisactivity.Afterthreehours,hereportedtheonsetof moderatepainintheanterolateralregionoftheleftleg,with noassociatedsignsofinflammation;theneurovascularexam- inationpresentedwithoutalterations.Commonanalgesicand cryotherapywere prescribed.Nine hoursafter the training session,hepresentedtothemedicaldepartmentwithcom- plaintofprogressiveworsening ofpain, visualanalogscale 8/10,edemainthe anterolateralregion oftheleft leg, and painwhenmobilizingtheextrinsicmusclesofthefootand ankle.Thelimbwasimmobilized,andcryotherapy,elevation, rest,andassociatedanti-inflammatorydrugswereprescribed.
Theathletepersistedwithsignificant painuntilthefollow- ing morning,whenthe beginning ofamotordeficit inthe territoryofthecommonfibularnerveandparesthesiainthe dorsallateralregionofthefootwereidentified.Onphysical examination,hepresentededemaintheanteriorandlateral compartmentoftheleftleg,decreasedsensitivityofthefirst interdigitalspaceoftheleftfoot,anddecreasedstrengthinthe anteriortibial(M3),longextensordigits(M3),andhallux(M0;
Fig.1).Posteriortibialanddorsalpedispulseswerepalpable, withcapillaryperfusionoflessthanthreeseconds,andno associatedpallor.Thepatientwasdiagnosedwithcompart- mentsyndrome;anemergencymagneticresonanceimaging wasperformed(Fig.2),andthepatientwasoperated24hafter theonsetofsymptoms.
Fig.1–Preoperativeclinicalevaluationindicatingreduced halluxextensionandalterationinthefunctionofthe anteriortibial.
Ananterolateralsegmentalfasciotomyoftheleftlegwas performed (Figs. 3and4),withimmediate improvementof pain and local appearance. The patient presented a good evolution,withnoresidualsensorydeficits,aswellastotal recoveryofthetibialisanteriorandflexordigitorumlongus (M5),butmaintainedapartialdeficit(M2)oftheflexorhallucis longusforeightpostoperativeweeks.
Discussion
Acutenon-traumaticcompartmentsyndromeafterphysical activityisarareclinicalentitythatinvolvesanacuteincrease inintracompartmentalpressuresecondarytointensephysical exercise,withoutahistoryofassociatedtrauma.Theliterature
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rev bras ortop.2018;53(2):244–247Fig.2–Magneticresonanceimagingindicatingsignal changesintheanterolaterallegmuscles.
Fig.3–Decompressivefasciotomywithfouranterolateral incisions.
Fig.4–Distalincisionindicatingthecolordifferenceinthe normalandpost-decompressionmuscles.
onthispathologyconsistsonlyofcasereportsandfewseries ofcases;thereisnoestimatedincidence.Livingstonetal.1 publishedaseriesofcasesofsevenpatientswithacutenon- traumaticcompartmentsyndrome,allyoungmaleathletes;
86%ofthepatientspresentedneurologicaldeficits,71%pre- sentedmuscleweakness,and51%hadaclinicalpresentation similartothatofthepresentpatient.Theirresultsindicateda 24-hcut-offpointfordecompressivefasciotomy:allpatients treatedbeforethisperiodevolvedwithoutlong-termsequelae.
Thepresentpatientwashealthy,previouslyasymptomatic, and ingoodphysicalshape.Hepresentedacutesymptoms three hours after standard soccer training, with no signs to warn ofcompartment syndrome.His case evolvedwith maintenanceof painand onset ofneurological symptoms;
he was kept under observation and subsequently taken to urgent surgery. The service in which he was initially treateddidnothaveintracompartmentalpressureevaluation methods,whichwouldhavehelpedinthediagnosisandcon- sequentlyledtoearliertreatment.Inpublishedliterature,2,3 non-traumatic compartmentsyndrome inathletes isoften diagnosed late, which is explained by the rarity of this condition andpresenceofothermorecommon differential diagnoses. Because the patient is an elite athlete, a mini- mallyinvasiveanterolateralfasciotomywasperformed,with four smallincisionsand totalfasciarelease.Maffullietal.4 publishedaprospectivestudyevaluatingminimallyinvasive fasciotomy in the treatment of lateral traumatic or non- traumatic anterolateral syndrome in athletes. The results indicatedthat94%ofthepatientsreturnedtosportactivity in8–13weeks.Traditionalfasciotomypresentsahigherrateof infectionandlongerhealingtime,factorsthatdelaythereturn tosports.4However,thefascialreleaseofatleast90%ofthe affectedcompartmenttoreturnintracompartmentalpressure tobasallevelsisessential,asdemonstratedbyMathisetal.5; intheory,thisreleaseismoredifficultinminimallyinvasive surgery.
Attwomonthspostoperatively,thepresentpatienthasno pain, presentingfullrecoveryofsensitivityand strengthin thetibialisanteriorandflexordigitorumlongus;however,the
rev bras ortop.2018;53(2):244–247
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deficitoftheflexorhallucislonguspersisted,possiblydueto itsmoreproximalinnervationbythenervefibularislongus.
Therecoverytimewassimilartothatfoundintheliterature,6–9 suchasintheretrospectivestudybyIrionetal.10onthereturn tophysicalactivity after fasciotomyforcompartment syn- dromeineliteathletes;84.6%returnedtothepreviouslevel 11weeksaftersurgery.
Despite the rarity ofacute non-traumatic compartment syndromeinathletes,orthopedistsandphysiciansinvolved insports should maintainahigh index ofsuspicionwhen examiningpatientswithdisproportionatelimbpainwithout etiology or historyof knowntrauma. The delayin diagno- sis and treatment is associated with muscle necrosis and high morbidity, which can leadto an early termination of an athlete’s career. Decompressive fasciotomy is the indi- catedtreatment;lessinvasivesurgerypresentsgoodresults,is estheticallyandfunctionallybetter,andpresentslowertime ofrecoveryandreturntosports.
Conflicts of interest
Theauthorsdeclarenoconflictsofinterest.
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