Acute Peroneal Compartment Syndrome Following Ankle Inversion Injury: A Case Report

Glenn G. Gabisan, and David R. Gentile

The American Journal of Sports Medicine

2004, Vol 32, pages 1059-1061.

Gabisan and Gentile report upon a case of acute peroneal compartment syndrome that should act as a reminder to all clinicians when the presentation of an ankle sprain is not 'typical'. This relatively rare condition can occur following a rupture of the Peroneus longus muscle, which causes a tense intra compartmental haematoma. As with other acute compartment syndromes, muscle and nerve tissue can suffer ischemic damage, with the potential to cause a permanent foot drop.

A 23-year-old man sustained a non-contact inversion injury to the left ankle during a flag-football competition. He felt a pop in his lower leg and developed immediate pain and a limp. The anterolateral left leg became increasingly painful 8 hours after the injury. He was seen at a local emergency department, but radiographs of the ankle were negative. He was discharged with the diagnosis of an ankle sprain, but he continued to have increasing pain in the anterolateral leg, which was not relieved by analgesics. At 24 hours after his injury, he was sent by his primary care physician to the emergency department.

On examination, the anterior and lateral compartments of the left leg were tense. He had decreased sensation on the dorsum and in the first web space of the left foot. He could not actively evert his foot, and attempting this caused pain. He could actively dorsiflex the ankle and toes against gravity, and there was no pain with passive flexion and extension of the toes. Passive inversion of the foot increased the pain at the anterolateral leg. Dorsalis pedis and posterior tibial pulses were palpable. Capillary refill was less than 2 seconds in the toes. Compartment pressures measured 130 mmHg in the lateral compartment and 60 mmHg in the anterior compartment. The superficial and deep posterior compartment pressures were less than 20 mmHg.

At 25 hours after his injury and 17 hours after the onset of anterolateral leg pain, fasciotomies of the anterior and lateral compartments were performed through a single lateral skin incision. The anterior compartment muscles appeared normal. The lateral compartment was tense with hematoma, and a tear in the peroneus longus muscle belly was found. The patient had immediate relief of his leg pain in the recovery room. He had only mild incisional discomfort and no lateral compartment pain with passive range of motion.

Remember: Peroneal compartment syndrome should remain in the clinician's differential diagnosis when evaluating a patient with a painful inversion injury. A tear in the peroneus longus muscle may lead to a compressive hematoma in the lateral compartment, causing a delayed compartment syndrome. Peroneal compartment syndrome requires prompt recognition, referral to an emergency department and fasciotomy to avoid permanent sequelae such as foot drop.

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