Acute Leg Pain in a Patient With Cellulitis

Case Study

A rapid response was initiated by the bedside nurse (RN) for a patient with severe leg pain. Upon the arrival of the rapid response team, the patient was a 48-year-old male with a known history of type 2 diabetes mellitus with insulin dependence, stage III chronic kidney disease, and chronic hypertension. The patient had been admitted two days earlier for lower extremity cellulitis, for which he was receiving broad-spectrum antibiotics. He had been experiencing increasing pain in his affected extremity over the past few hours before the rapid response event was initiated. He reported new numbness of 15 min duration to the code team.

Vital Signs

Temperature: 100.2 °F, oral
Blood Pressure: 125/70 mmHg
Heart Rate: 125 beats per min (bpm), sinus tachycardia on telemetry
Respiratory Rate: 35 breaths per min
Pulse Oximetry: 99% saturation on room air

Focused Physical Examination

A quick exam revealed an overweight male lying in bed in severe distress. The lower extremity exam showed erythema and swelling of the left leg. The erythema had spread beyond the margins of the border that was drawn earlier in the day. There was no evidence of pallor or cyanosis of the toes, feet, or leg. The range of movements was intact at the left knee, as was plantarflexion. The patient was unable to dorsiflex his left ankle. The extremity was warm to touch, and the calf was extremely tender to palpation. Posterior tibial and dorsalis pedis were not palpable. However, the bedside RN could locate the posterior tibial pulse in the affected extremity with Doppler.

Interventions

The patient was immediately given 2 mg IV morphine for pain relief. Stat consult was called to orthopedic surgery for evaluation of the patient’s lower extremity. Bedside manometry was done by the surgical team, which showed a pressure of 35 mmHg in the anterior compartment. The patient was taken immediately to the operating room for emergent fasciotomy.

Final Diagnosis

Acute compartment syndrome in a patient with cellulitis.

Acute Compartment Syndrome

Human limbs are organized into groups of muscles divided by thick fascial membranes. These sections or compartments are limited-space areas with neurovascular bundles traversing the space to supply distal parts of the body. Any increase in the volume of this closed compartment would lead to compression of the blood vessels and nerves, which is the basic underlying pathophysiology of acute compartment syndrome. Table 62.1 lists some common traumatic and non-traumatic causes of acute compartment syndrome.

Table 62.1

Common causes of acute compartment syndrome

Traumatic	Non-traumatic
• Fractures – open or closed (~75% of cases) • Tibia fractures – most common • Supracondylar humeral fractures • Crush injuries • Severe thermal burns • Constrictive circumferential bandages, casts, or splints • High-pressure injections • Vascular injury • Animal bites	• Reperfusion injury – post-embolectomy, thrombolysis, or bypass • Hemorrhage • Thrombosis • Anticoagulation • Injections of illicit drugs • Extravasation of fluids • Prolonged compression of the limb • Infection of musculature • Rhabdomyolysis