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Acute Compartment Syndrome Leading to Bilateral Foot Drop in Association with Hypothyroidism | OMICS International
ISSN: 2165-7920
Journal of Clinical Case Reports
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Acute Compartment Syndrome Leading to Bilateral Foot Drop in Association with Hypothyroidism

Joe Thomas1*, Vimal Iype2 and Joice Varghese3

1Department of Rheumatology, Lourdes Hospital, Kochi, Kerala, India

2Department of Vascular Surgery, Lourdes Hospital, Kochi, Kerala, India

3Department of Orthopaedics, Lourdes Hospital, Kochi, Kerala, India

*Corresponding Author:
Joe Thomas
Department of Rheumatology
Lourdes Hospital, Kochi, Kerala, India
Tel: +91 484 4123456
E-mail: [email protected]

Received March 26, 2016; Accepted April 22, 2016; Published April 30, 2016

Citation: Thomas J, Iype V, Varghese J (2016) Acute Compartment Syndrome Leading to Bilateral Foot Drop in Association with Hypothyroidism. J Clin Case Rep 6:782. doi:10.4172/2165-7920.1000782

Copyright: © 2016 Thomas J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Acute compartment syndrome (ACS) most often develops soon after significant trauma, particularly involving long bone fractures. However, ACS may also occur following minor trauma or from non-traumatic causes. ACS is a surgical emergency. We report an unusual case of acute compartment syndrome leading to bilateral foot drop in association with hypothyroidism.

Keywords

Acute compartment syndrome (ACS); Bilateral foot drop; Hypothyroidism

Introduction

Compartment syndrome has been defined as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space” [1,2]. Compartment syndrome may occur acutely, often following trauma, or as a chronic syndrome, seen most often in athletes, that presents as insidious pain. Acute compartment syndrome (ACS) is a surgical emergency. We report an unusual case of acute compartment syndrome leading to bilateral foot drop in association with hypothyroidism.

Case Report

32 year male working at Kuwait, presented to our hospital with sudden onset of bilateral painful foot drop. He was apparently well and had gone for shopping with his relatives, which lasted for 5 hours. Next day morning on routine morning walk, he developed sudden onset of pain in both lower limb and was unable to walk any further. He was immediately taken to a local hospital and was found to have bilateral foot drop. A provisional diagnosis of inter vertebral disc prolapse with bilateral foot drop was made and was treated with three pulses of 1 gm methylprednisolone. After 5 days, as there was no improvement, he was brought to our hospital.

On examination he was obese (BMI 35), vital were stable, there was bilateral foot drop with MRC grade 0/5 power in the dorsiflexors of the ankles and extensors of the toes (Figure 1). The sensations for fine touch and pinprick over the first interdigital cleft on the dorsum of both the feet were diminished, bilateral ankle reflexes were sluggish. He had tender, tense with a firm “wood-like” feeling in both in the lower extremity. The rest of the systemic examination was normal.

Figure 1: B/L foot drop.

Laboratory assessments showed Total count 15600 cells/μl with 77 % neutrophils, creatine phosphokinase (CPK) was 13370 IU/L, TSH >100 μIU/ml (0.3-4.2), T3 81 μg/dl (85-202), T4 2.32 μg/dl ( 5.1-14.1). His renal functions and electrolytes were normal. Nerve conduction studies showed deficiencies in the tibial and peroneal muscle responses supportive of common peroneal nerve palsy. MRI of lumbar spine showed L5/S1 disc prolapsed with no significant canal impingement. Compartment pressure in the lower leg was measured which was more than 35 mmHg. A diagnosis of acute bilateral compartment syndrome was made and patient underwent bilateral four compartment fasciotomy of the leg (Figure 2). The lower end of left anterior fasciotomy shows a patch of whitish tissue which is dead muscle. This was just the tip of Ice berg, his whole anterior and lateral compartment muscles along with the thrombosed anterior tibial artery and vein had to be excised. Needed serial debridements and four weeks of vacuum dressings for wound to heal. Pt was started on thyroid replacement therapy, along with broad spectrum antibiotic coverage. Over the next few weeks he underwent rehabilitation and he had partial recovery of his food drop.

Figure 2: The lower end of left anterior fasciotomy shows a patch of whitish tissue which is dead muscle.

Discussion

ACS most often develops soon after significant trauma, particularly involving long bone fractures. However, ACS may also occur following minor trauma or from non-traumatic causes. ACS in a patient with hypothyroidism was first reported in 1993 [3] and subsequently two more case were reported [4,5]. All cases recovered with conservative treatment, where as our case required fasciotomy, which indicates severity. Multiple explanations for the complex pathophysiology of ACS exist [6]. In all cases, the final common pathway is cellular anoxia [7]. A prerequisite for the development of increased compartment pressure is a fascial structure that prevents adequate expansion of tissue volume to compensate for an increase in fluid.

Early symptoms of ACS include progressive pain out of proportion to the injury; signs include tense swollen compartments and pain with passive stretching of muscles within the affected compartment. Important clues to the development of ACS include rapid progression of symptoms and signs over a few hours and the presence of multiple findings consistent with the diagnosis in a patient at risk. Close observation and serial examinations in patients at risk for ACS are of great importance. Motor deficits are late findings associated with irreversible muscle and nerve damage. Immediate surgical consultation should be obtained whenever ACS is suspected based upon the patient’s risk factors and clinical findings.

Conclusion

This case illustrates the need to consider the diagnosis of compartment syndrome in a patient presenting with bilateral foot drop and prompt intervention is essential.

References

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Review summary

  1. Beverly
    Posted on Jul 29 2016 at 6:32 pm
    The article presents an unusual case of bilateral foot drop in a patient with previously undiagnosed Hypothyroidism. Eventhough, hypothyroidism with rhabdomyolysis and compartment syndrome has already been documented but the reported case is highly unusual. The article possess high applicability in clinical research.

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