Page 24 - Journal of Special Operations Medicine - Fall 2016

The paratrooper reported that during the flight, he was total protein of 100mg/dL, and a decreased glomerular
2
immobilized by adjacent and tightly packed passengers filtration rate of 64mL/min/1.73m . LFTs showed an
and by surrounding rucksacks that pinned him in posi- aspartate transaminase level of 862U/L that reached a
tion and added to the weight supported by his lap. He maximum of 1,762U/L and an alanine aminotransferase
noted specifically that he was unable to move his legs at level of 233U/L that reached a maximum of 520U/L on
all during the flight, and that his left leg was supporting hospital day 2. The patient’s total CPK of 77,900U/L
a majority of the weight from the equipment. He was trended up to a maximum of 102,380U/L on hospi-
also wearing knee pads that wrapped tightly around tal day 2. His D-dimer level was elevated to 19.6mg/L
both legs. He fell asleep for an unknown duration dur- fibrinogen-equivalent units (FEU). Urine drug screen,
ing the flight. blood gas levels, and hepatitis screens were normal. An
abdominal ultrasound was unremarkable, and ultra-
When he started receiving jump commands, he noted sound of the left lower extremity showed no evidence
left leg numbness, pain of 8–9 on a 0–10 scale, and dif- of thrombosis or other abnormality. Plain film radio-
ficulty moving the distal limb. He attempted to stand graphs and magnetic resonance imaging without con-
but collapsed on doing so. After a second failed attempt trast of the lumbar spine showed no clinically significant
at ambulation, he was ordered not to jump and placed abnormalities.
back in his seat by the jumpmaster safety, an infantry
officer with no medical training. When the aircraft Hospital Course
made a scheduled landing in Alexandria, Louisiana, for
refueling, the patient’s symptoms were unchanged. The While some improvement in motor function was noted
jumpmaster made the decision to have the patient trans- in the left foot after admission and after 2 days of con-
ported to a nearby civilian hospital for further evalua- servative therapy with intravenous fluids, mannitol, and
tion and treatment. analgesics, the paratrooper remained markedly weak
with dorsiflexion and toe extension, and progressive
Physical examination revealed a heart rate of 96 beats pain, swelling, and erythema of the left lower leg were
per minute and blood pressure of 139/80mmHg. There noted in the anterior and lateral compartments. A neu-
was absent sensation over the dorsum of the foot in a rologist was consulted and the patient was diagnosed
superficial fibular nerve distribution, as well as the in- with left fibular neuropathy. A general surgeon evalu-
terdigital space between the left first and second toes ated the patient, documented pain with passive plan-
in a deep fibular nerve distribution. The patient was tarflexion of the left ankle, and was concerned about
initially unable to move the distal left lower extremity anterior and lateral compartment syndrome based on
at all. Subsequent re-evaluations noted a return to nor- the clinical findings. The patient was taken to surgery
mal plantar flexion, although he continued to have only on hospital day 3 and underwent a fasciotomy of the left
trace movement with attempts at dorsiflexion and toe anterior and lateral compartments.
extension. There was no documentation regarding the
patient’s response to passive plantarflexion. Inversion Intraoperative findings noted mild to moderate edema
and eversion were improving but also notably weak. in the lateral compartment and severe edema in the ante-
The patient had normal dorsalis pedis pulses and ini- rior compartment with gray muscle protruding from the
tially had a normal appearance of the left leg, although fascia. By hospital day 5, the patient’s pain and swelling
he reported a pressure sensation in the anterior portion were improving and the abnormalities in his laboratory
of the leg, and gradual, painful swelling and cellulitic results were downtrending. He was taken back to sur-
changes were noted over the next 2 days. Anterior and gery on hospital day 5 with noted reduction of swelling
lateral compartment tenderness to palpation also de- and absence of infection or necrotic muscle. The fasciot-
veloped over the first 2 days of hospitalization, but the omy wound was closed and the patient was monitored
posterior compartment remained unaffected. The right for two more days before being discharged to a military
lower extremity functioned normally. treatment facility for further care and rehabilitation.

Initial laboratory examinations included a basic meta- Discussion
bolic panel (BMP), complete blood cell count, urinalysis
(UA), liver function tests (LFTs), total keratinize phos- The leg consists of four compartments: anterior, lateral,
phokinase (CPK), urine drug screen, a hepatitis panel, superficial posterior, and deep posterior. The anatomy
D-dimer, and blood gases. The BMP was unremarkable, of these compartments, including their respective mus-
including blood urea nitrogen and creatinine levels, with cles, arteries, veins, and nerves, is depicted in Figure 1.
the exception of a potassium level of 5.3mmol/L. The Any of these compartments can develop compartment
UA showed grossly tea-colored urine with large amounts syndrome, but the anterior and lateral compartments
of blood noted on urine microscopy, an elevated urine are more commonly affected. ACS occurs when there is

6 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2016