Acute compartment syndrome following dvt

1. CASE REPORT
Acute compartment syndrome following
therapeutic anticoagulation for suspected DVT
I.E. Collins *, J. Waite, R. Gundle
Department of Orthopaedics, Nuffield Orthopaedic Centre, Oxford OX37LD, UK
Accepted 10 November 2004
Case report
A fit and well 25-year-old male presented to the
minor injuries unit of a community hospital at the
weekend. He complained of gradual onset of a
swollen and painful calf following football training.
He had also undertaken a short haul flight 3 days
prior to presentation. He had no risk factors for DVT.
He was thought to be suffering with a DVT and was
therefore referred to a DVT clinic, where a thera-
peutic dose of Fragmin, 15,000 units (Pharmacia and
Upjohn Ltd., Milton Keynes) was given subcuta-
neously. An ultrasound scan was organised for the
following morning.
Six hours later, the gentleman was referred to
Accident and Emergency by his general practitioner
with severe right lower leg pain and tense calf
swelling. He could not weightbear on the right leg
due to pain. He developed paraesthesiae in his lower
leg, although objective sensory examination was
normal. The pain was exacerbated by active ankle
dorsiflexion, although passive ankle and toe exten-
sion did not increase his pain. Distal lower limb
pulses were normal.
Blood tests showed D-dimers raised at 1449 (nor-
mal range 0—500). CRP was raised at 30 and WBC
raised at 12.6 Â 109
/l. His prothrombin time was
normal at 13.4 but his APTTwasraised at41.0 (normal
range 24.0—34.0). His haemoglobin was normal at
15.3 g/dl. Compartment syndrome of the superficial
posterior compartment was diagnosed.
Emergency formal decompression of all four com-
partments of the right lower leg were performed by
fasciotomy. Intraoperatively, a tense haematoma
within gastrocnemius was evacuated. Partial necrosis
of both medial and lateral heads of gastrocnemius
required debridement. An estimated 20% of total
gastrocnemius muscle bulk was non-viable. The ante-
rior, lateral and deep posterior compartments con-
tained healthy tissue. Following thorough irrigation,
the lateral wound was closed. The medial wound was
left open. Intraoperative blood loss was estimated at
2285 ml. Postoperative haemoglobin had dropped to
10.0 g/dl but his renal function was normal. A good
urinary output was maintained. His creatine kinase
was 397 indicating the absence of acute rhabdomyo-
lysis. The medial wound was re-inspected at 48 h, but
no further necrotic muscle was found. Partial wound
closure was achieved, but completion of closure
required a further operation four days later.
Discussion
The clinical diagnosis of DVT is notoriously unreli-
able, with diagnostic accuracy ranging between
Injury Extra (2005) 36, 253—254
www.elsevier.com/locate/inext
* Corresponding author. Tel.: +44 1865 741155;
fax: +44 1865 227874.
E-mail address: ionacollins@doctors.org.uk (I.E. Collins).
1572-3461 # 2004 Published by Elsevier Ltd.Open access under CC BY-NC-ND license.
doi:10.1016/j.injury.2004.11.023

2. 1.210
and 30%.7—9
Until recently, therapeutic antic-
oagulation for DVTwas deferred, pending confirma-
tion of the diagnosis by ultrasound scan or
venogram. However, the provision of these services
outside of normal working hours has placed an
enormous burden on radiographers, with some cen-
tres consequently losing staff.10
This problem has
resulted in the development of pre-emptive hepar-
inisation,2,10
the implementation of which has been
endorsed by the Department of Health.5
Initiating anticoagulation treatment without a
definitive diagnosis of DVT is potentially hazardous.
Gastrocnemius tear or haematoma usually resolves
spontaneously with no long-term sequelae. In this
case, the administration of heparin in the presence
of a gastrocnemius tear appears to have stimulated
further haemorrhage, increasing intra-compart-
mental pressure and precipitating acute compart-
ment syndrome.
The Department of Health-funded Prodigy web-
site states that in clinically-suspected DVT, diagnos-
tic imaging should be performed within 24 h, if
possible. It also states that heparin should be com-
menced (unless strongly contraindicated) until the
diagnosis is excluded by such imaging. Differential
diagnoses for DVT are listed, which includes muscle
tear; however, the potential complications of antic-
oagulation in this group are not mentioned.
The Scottish Intercollegiate Guidelines Network
(SIGN)6
guidelines state that if diagnostic imaging is
not immediately available, heparin should be com-
menced unless strongly contraindicated and objec-
tive testing performed as soon as is feasible. The
SIGN guidelines also state that a low molecular
weight version of heparin possibly carries a lower
risk of haemorrhage compared with other forms of
heparin.
Long haul flights may be associated with DVT, but
there are no published data to suggest an increased
DVT risk following short haul flights.
Although the absence of D-dimers, when clinical
suspicion of DVT is low, has proved useful in reducing
the number of radiographic investigations,12
a posi-
tive D-dimer test, is a poor indicator of thrombosis
due to its lack of specificity. D-dimers are often
raised in association with inflammation, infection,
postoperative haemorrhage and trauma.3
Studies1,4
have suggested that pre-diagnostic administration
of therapeutic heparin is safe and may reduce the
risk of pulmonary embolism while awaiting a defi-
nitive diagnosis. However, it has also been reported
that heparinisation increases the risk of acute com-
partment syndrome secondary to haemorrhage.1,11
Summary
Preemptive heparinisation for clinically suspected
DVT is perceived as safe practice with virtually no
complications reported.5
However, this case high-
lights the risk of causing acute compartment syn-
drome when heparin is given for clinically-suspected
DVT, when the actual diagnosis is a gastrocnemius
tear.
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254 I.E. Collins et al.