Page 26 - Journal of Special Operations Medicine - Fall 2016

of malpractice cases between 1998 and 2003 involving this history was absent in our patient, we considered
compartment syndrome and identified factors that can that the seats on an Air Force C-130 aircraft are essen-
confound the diagnosis, such as altered mental status, tially nylon cargo netting stretched over a few metallic
perioperative narcotics, and fluctuating physical signs. bars, including a bar that is situated just proximal to the
Furthermore, the authors noted that patient symptoms knee. This bar, as well as the patient’s kneepad straps
that were not further investigated, such as numbness and increased flexion of the joint for several hours, may
and subtle weakness, played a significant role in liti- have combined to cause a nonanatomic entrapment of
gated cases. ACS due to nontraumatic etiologies may the popliteal artery. If the entrapment preferentially af-
5
be less apparent to evaluating providers. A high level fected blood flow through the anterior and posterior
of suspicion must be maintained, considering the varied tibial arteries, both of which arise from the popliteal ar-
circumstances that may provoke this condition. tery, then decreased perfusion affecting the anterior and
lateral compartments may have occurred and contrib-
To our knowledge, the patient described here represents uted to the development of ACS. Although older stud-
the first reported case attributing ACS to the immobi- ies suggested several hours of ischemia were needed to
lization and load-bearing burden experienced by para- produce nerve and muscle damage, recent data suggest
troopers during the prejump phase. Paratroopers are such injury occurs within the first 3 hours. 18
unique in that they are required to carry heavy loads,
often in excess of 100 lb, to sustain themselves in an This case demonstrates the possibility of ACS develop-
austere environment for 72 hours while awaiting resup- ing in Soldiers who are in prolonged states of immobi-
ply. Furthermore, paratroopers may be immobilized for lization while simultaneously bearing heavy equipment
hours while waiting to board their aircraft or in flight. loads. Airborne Soldiers, in particular, may be at risk for
We believe the underlying mechanism in this case to be such complications during the prejump timeline. In our
the result of both external compression and reperfusion experience, paratroopers who are unable to complete
injury. Prior case reports and reviews have established their jumps are triaged and treated by in-flight medics
an association between prolonged immobilization and and sent to the nearest emergency department, where
the development of pressure-related compartment syn- they are often diagnosed with dehydration-induced
drome in the extremities. Moriano-Béjar et al., for ex- rhabdomyolysis. Our patient, however, demonstrates
6
ample, reported a case of lower extremity compartment the possibility for more serious underlying pathology.
syndrome involving the anterior compartment develop- Certain situations, such as those involving extrem-
ing in a lumbar surgery patient, which was believed to ity pain, should raise the level of concern and a more
be due to the pressure applied to the anterior compart- detailed evaluation should be considered. Unit leaders
ment while in the knee-chest position. Shriver et al. should be aware of the potential for ACS under such
7
conducted a review and found that, although rare, com- conditions. Adding weight to these Soldiers’ already-
partment syndromes appeared related to areas of pres- heavy equipment loads should be avoided, and Soldiers
sure applied during intraoperative positioning and that should be mobilized or shifted when possible to prevent
such complications appeared to occur with surgeries prolonged compression of tissues or vasculature. Med-
lasting longer than 2–4 hours. Likewise, several other ics, physician assistants, battalion surgeons, and emer-
case reports involving immobilization and prolonged gency medicine providers should also be aware of and
intraoperative positioning have reported ACS as a com- monitor for ACS in these Soldiers so it can be identified
plication, 8–10 as have several reports of patients immobi- and treated promptly.
lized for prolonged periods due to drug intoxication. 11–12
Since our patient reported early and severe lower ex- Disclosures
tremity pain with his attempts to stand, we believe that
compression of the anterior and lateral compartments of The authors have nothing to disclose.
the left leg contributed to his initial symptoms.
References
We further suspect reperfusion injury to be a significant
contributing factor in this case. ACS is well described 1. Frink M, Hildebrand F, Krettek C, et al. Compartment Syn-
in association with tourniquet use and in involving drome of the lower leg and foot. Clin Orthop Relat Res.
13
2010;468:940–950.
injuries that cause a tourniquet-like effect. ACS has 2. Styf J. Compartment syndromes. Boca Raton, FL: CRC Press;
14
been reported in cases of popliteal artery entrapment 2004.
syndrome that were attributed to a congenital arterial 3. Bowyer MW. Compartment syndrome. In: Gahtan V, Costanza
anomaly or intermittent entrapment of the vessel by MJ, eds. Essentials of vascular surgery for the general surgeon.
New York, NY: Springer; 2014:55–69.
the gastrocnemius. This condition is most common in 4. von Keudell AG, Weaver MJ, Appleton PT, et al. Diagnosis and
young athletes who present with symptoms of, chronic, treatment of acute extremity compartment syndrome. Lancet.
intermittent claudication with exertion. 15–17 Although 2015;386:1299–1310.

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