A thirty-five-year-old man sustained a severe inversion sprain of the right ankle while playing basketball. Approximately ninety minutes after injury, the patient was seen by his primary care provider, who prescribed treatment at home with rest, ice, elevation, and a compressive dressing. The patient returned to the primary care provider five hours after injury with increasing swelling of the ankle. Pneumatic intermittent impulse compression (PlexiPulse; Kinetic Concepts, San Antonio, Texas) was applied to the foot for one hour in the primary care setting, and conservative treatment at home was again prescribed. Pain and swelling increased through the night, and the patient returned to the primary care provider the following morning. Examination of the foot twenty-six hours after injury revealed marked, tense swelling involving the entire foot and ankle with circumferential blistering of the skin (
Figs. 1-A and 1-B ). Orthopaedic consultation was then obtained.
When the patient was examined at our facility, sensation to light touch was decreased throughout the foot and the patient experienced extreme pain with passive stretch of the toes. The posterior tibial and dorsalis pedis pulses were not palpable; however, capillary refill was brisk (less than one second) in all toes. Plain radiographs of the foot and ankle demonstrated no fractures.
Dorsal compartment pressures were measured with a Stryker 295 Intra-Compartmental Pressure Monitor System (Stryker, Kalamazoo, Michigan) and were in excess of 120 mm Hg between the second and third metatarsals and the third and fourth metatarsals, confirming the diagnosis of a compartment syndrome of the foot.
The patient was taken emergently to the operating room. Fluoroscopic stress testing demonstrated no evidence of occult ligamentous instability of the midfoot. Testing for instability of the ankle and the subtalar joint was limited by the turgescent nature of the soft tissues about the foot and ankle. Fasciotomies were then performed through two dorsal incisions along the second and fourth rays and through a single medial plantar incision
10 . The underlying muscle immediately bulged and then appeared adequately perfused without evidence of necrosis.
Approximately 100 cc of congealed hematoma was bluntly evacuated proximally from around the ankle joint through the most lateral incision. Rather brisk arterial bleeding was then encountered. Doppler examination showed an intact signal for the entire posterior tibial artery and anterior tibial artery to the level of the ankle joint but loss of the signal for the dorsalis pedis artery distally. A coagulation panel (partial thromboplastin time, platelet count, fibrinogen level, and liver function tests) obtained during the operation showed no abnormalities. The bleeding, however, appeared to slow appreciably with local compression. The incisions were left open, and a sterile bulky compression dressing was applied.
After the operation, the patient reported that the pain had decreased dramatically and that he no longer experienced any pain with active or passive motion of the toes. Capillary refill in the toes remained brisk; sensation, however, remained diminished throughout the entire foot. By forty-eight hours after the operation, the dressing had become saturated with blood. The level of hemoglobin had decreased from 105 g/L on admission to 63 g/L, but no signs of hemodynamic instability were present. The patient was then taken back to the operating room with plans for a repeat débridement and delayed primary wound closure. Again, large amounts of congealed hematoma, which appeared to have formed in the soft tissues proximally around the ankle, were evacuated from the wounds. The muscles appeared viable, and the soft tissues were copiously irrigated with pulsed lavage. Arterial bleeding was again encountered; a compression dressing was applied and an arteriogram was made on an emergent basis.
Arteriography demonstrated disruption of the anterior tibial artery at the level of the ankle joint well proximal to the surgical incisions (
Fig. 2 ). Vascular surgery consultation was then obtained. The patient underwent an uncomplicated reverse interpositional vein graft harvested from the ipsilateral saphenous vein to reestablish antegrade flow through the dorsalis pedis artery.
The patient ultimately required transfusion of four units of packed red blood cells and remained on triple antibiotic therapy until the surgical wounds were subsequently closed by delayed primary closure. Satisfactory débridement of the desquamative epidermis was accomplished by way of whirlpool treatment and topical application of Silvadene Cream (silver sulfadiazine). Skin-grafting was not required.
Examination two years after surgery demonstrated a full active range of motion of the ankle. No contractures of the toes or deformities of the foot were noted. There had been continued loss of pigmentation of the right foot (
Fig. 3 ). No appreciable sensory loss about the foot and ankle was noted on examination. Posterior tibialis and dorsalis pedis pulses were palpable. Seventy-seven months after injury, the only symptoms with regard to the involved ankle were occasional swelling and numbness after airplane flight. The patient had returned to full activity, including parachute jumping, without limitations.