An 88-year-old man is evaluated due to severe right calf pain several hours after undergoing a right femoral artery embolectomy. He also has a burning sensation in the posterior aspect of the right leg. The patient has persistent atrial fibrillation and hypertension. His medical history also includes an ischemic stroke, bleeding duodenal ulcer, type 2 diabetes mellitus, and diabetic nephropathy. Temperature is 36.5 C (97.7 F), blood pressure is 160/70 mm Hg, and pulse is 100/min and irregular. The right calf is swollen, tense, and exquisitely tender, with pain that is worse with passive dorsiflexion of the ankle. The skin is shiny and cool to the touch. Sensation over the leg is decreased and the patient is unable to move his toes. Dorsalis pedis and posterior tibial pulses are palpable. Which of the following is the most likely cause of this patient's symptoms?

Question

An 88-year-old man is evaluated due to severe right calf pain several hours after undergoing a right femoral artery embolectomy.  He also has a burning sensation in the posterior aspect of the right leg.  The patient has persistent atrial fibrillation and hypertension.  His medical history also includes an ischemic stroke, bleeding duodenal ulcer, type 2 diabetes mellitus, and diabetic nephropathy.  Temperature is 36.5 C (97.7 F), blood pressure is 160/70 mm Hg, and pulse is 100/min and irregular.  The right calf is swollen, tense, and exquisitely tender, with pain that is worse with passive dorsiflexion of the ankle.  The skin is shiny and cool to the touch.  Sensation over the leg is decreased and the patient is unable to move his toes.  Dorsalis pedis and posterior tibial pulses are palpable.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d8ab_141e_bc81_95ec97d51936_MD0003_00 This patient's acute pain and paresthesias following a lower extremity embolectomy are likely due to ischemia-reperfusion syndrome, a form of compartment syndrome (CS). CS is a limb-threatening condition caused by increased pressure within an enclosed fascial space that limits perfusion of muscle and nerve tissues. It is most common following traumatic injuries (eg, long-bone fracture) or prolonged compression of an extremity but may also occur following reperfusion of an acutely ischemic limb due to interstitial edema and possibly intracellular swelling. The diagnosis of CS can be confirmed by measuring compartment pressures (eg, needle manometry); a delta pressure (diastolic blood pressure − compartment pressure) ≤30 mm Hg is strongly suggestive of CS. Definitive management includes urgent fasciotomy, although some patients may be managed conservatively with close observation if compartment pressures are falling and delta pressures are rising. (Choice B) Deep-tissue infection (eg, necrotizing fasciitis, clostridial gas gangrene) is commonly due to group A Streptococcus or mixed anaerobic infection. Like CS, these syndromes can present with severe pain out of proportion to clinical signs, but symptoms generally evolve over several hours to days and are usually associated with skin necrosis, bullae, crepitus, and significant systemic toxicity (eg, high fever, hypotension). (Choice C) Recurrent embolism may produce features similar to CS (eg, severe pain, paresthesias) but would typically be associated with absent pulses, pallor of the affected limb, and lack of local swelling. (Choice D) Vaso-occlusive crisis is a complication of sickle cell disease characterized by severe pain and tissue ischemia. Episodes are typically precipitated by dehydration, cold, exertion, or hypoxemia, and typically manifest in early childhood with recurrent crises. Examination findings may include erythema and warmth, but swelling is unusual and clinical features are often bilateral and symmetric. (Choice E) Deep venous thrombosis may cause calf pain and swelling, but severe pain and sensory or motor deficits are more consistent with CS. Educational objective: Ischemia-reperfusion syndrome is a form of compartment syndrome that occurs following reperfusion of an acutely ischemic limb. Symptoms include severe pain that is worsened on passive range of motion, paresthesias, and sensory and motor deficits. The diagnosis is confirmed by measuring compartment pressures. Definitive management includes urgent fasciotomy. References: Acute compartment syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/27241376) Acute limb ischemia. (http://www.ncbi.nlm.nih.gov/pubmed/30243449)

An 88-Year-Old Man Is Evaluated Due to Severe Right Calf