Case Study – Lower Extremity

Case Study – Lower Extremity in $9 only

Presentation/History

At the beginning of the soccer season a 20-year-old college student participated in strenuous filed practice extending through the whole afternoon. Later in the evening he experienced severe pain over the anterolateral aspect of his right leg, radiating down toward the angle. The next afternoon he went back to the field and continued to play, but the pain in his right leg became so severe that he had to limp off the field. The pain persisted throughout the night and the next morning he consulted a physician.

Examination

On examination there is reddening and swelling over the anterolateral aspect of his right leg. On palpation this area is extremely tender, it feels hard and warmer than other parts of the leg. The hardening extends from two inches below the tibial tuberosity to the junction of the middle and lower thirds of the leg and seems to correspond to the belly of the tibialis anterior muscle. Dorsiflexion of foot and toes is severely limited. The pulses in the anterior tibial and dorsalis pedis arteries are present. His body temperature is slightly elevated.

Discussion ThreadQuestions
The condition is caused by an acute impairment of the intramuscular circulation in the muscles of the anterior compartment of the leg. It is assumed that heavy exercise, particularly in an individual who is not conditioned, causes a swelling of the musculature, perhaps also some tearing of muscle fibers and small hemorrhages inside the muscles. This increase in bulk compresses the smaller vessels within the muscle bellies which in turn leads to degeneration and necrosis of muscle fibers. The tibialis anterior is particularly affected, and the extensor hallucis longus is affected to a greater extent and more commonly than the extensor digitorum longus and peroneus tertius.Identify the muscles in the anterior compartment of the leg.

What in the configuration of the anterior compartment makes this region particularly liable to an increase in intracompartmental pressure?

The major nerve and blood vessels in the compartment may also be affected by the elevation in pressure.Identify the major nerves and blood vessels in the compartment.
This is best approached by considering what muscle supplied by the deep peroneal nerve lies outside the compressed compartment, the paralysis of which could be taken as an indication of direct nerve involvement. Note: Its paralysis would prove that the compression involves the deep peroneal nerve within the compartment.How would you test for involvement of the deep peroneal nerve, keeping in mind that dorsiflexion of foot and toes may be severely interfered with by anoxia (lack of oxygen) of the muscles in the compartment, and that loss of muscle action therefore does not necessarily imply nerve involvement?
Deficiencies in the sensory supply of the skin would also demonstrate that the deep peroneal nerve is directly affected.What area of the skin would you test for sensory loss?
The presence of arterial pulse in the anterior tibial and dorsalis pedis arteries seems to prove patency of the main stem, although, occasionally, a well-established collateral circulation in the lower part of the leg by means of branches from the arteries in the posterior compartment may simulate patency in a vessel blocked higher up.What vessel in the posterior compartment would particularly contribute to such collateral circulation?

Where do you feel the pulse of the anterior tibial artery?

Remember that this artery is directed across the dorsum of the foot to the proximal end of the first intermetatarsal space and lies on the skeleton of the foot just lateral to the tendon of the extensor hallucis longus.Where would you palpate the pulse of the dorsalis pedis artery?
The variations in susceptibility of the three main muscles of the anterior compartment to impaired circulation can be explained by differences in the development of the intramuscular arterial anastomoses. Another explanation, frequently offered, is the fact that the anterior tibial muscle has its sole supply from the anterior tibial artery, the less involved extensor hallucis longus receives additional blood from the perforating branch of the peroneal artery, while the extensor digitorum longus obtains its supply from the three major arteries of the leg, including the posterior tibial by way of perforating branches. This latter explanation of the preferential involvement of the anterior tibial muscle presupposes interference with blood flow in the main stem of the anterior tibial artery by elevation of pressure inside the compartment, before its branches enter the musculature. While this occurs, presence of pulsatory excursions in the anterior tibial artery distally and in its continuation, the dorsis pedis artery, as was found in this case, makes such an event improbable.

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Within the Discussion Forum, develop a working diagnosis and associated treatment plan for this patient.

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