Introduction Compartment syndrome is defined as a symptom complex caused by increased pressure of tissue fluid in a closed osseofascial compartment which interferes with circulation to the myoneural components of the compartment. Bilateral compartment syndrome of the legs is a rare presentation requiring emergent surgical intervention. In a recent case report (Khan et al 2012) there have been only eight reported cases cited with bilateral compartment syndrome. Heroin abuse is known to cause compartment syndrome, traumatic and atraumatic rhabdomyolysis. Hypothyroidism can also independently present with rhabdomyolysis. Case presentation We present a case of a 22 years old female who presented with bilateral swelling of the legs with associated loss of sensation having spent two days kneeling against the wall following IV heroin abuse. She presented to the emergency department with bilateral swelling of the legs with loss of sensation. She was diagnosed with compartment syndrome requiring emergent bilateral 4 compartment fasciotomy of the lower extremities. Inspite of aggressive fluid resuscitation she developed rhabdomyolysis complicated by acute renal failure requiring dialysis. She made a full recovery with full return of her renal as well as motor and sensory function. Conclusion We discuss this interesting case of bilateral compartment syndrome in a heroin abusive patient with history of hypothyroidism complicated by rhabdomyolysis and acute renal failure. There have been isolated case reports of bilateral compartment syndrome following prolonged surgery. High index of suspicion, early recognition and therapeutic intervention is the key to good outcome. We discuss the etiopathology and management options of rhabdomyolysis. Treating the comorbities like hypothyroidism is also important for the recovery. How to cite this article Biswas S, Rao RS, Duckworth A, Kothuru R, Flores L, Abrol S. Bilateral Atraumatic Compartment Syndrome of the Legs Leading to Rhabdomyolysis and Acute Renal Failure Following Prolonged Kneeling in a Heroin Addict. A Case Report and Review of Relevant Literature. J Trauma Critical Care Emerg Surg 2013;2(3):139-145.

Aims This study aims to determine whether intraoperative intravenous (IV) tranexamic acid (TXA) affects blood loss following the surgical management of femoral fragility fractures (FFF). Methods This was a single centre (university teaching hospital) non-randomised case-control study. There were 361 consecutive patients with FFF admitted over a 4-month period were included (mean age 81.4yrs; mean BMI 23.5; 73.7% female). Patient demographics, comorbidities, preoperative anticoagulation use, surgical management, intravenous TXA use, perioperative haemoglobin (Hb) and haematocrit, and requirement for blood transfusion were recorded. The primary outcome was postoperative blood transfusion requirement. Secondary outcomes included postoperative day one calculated blood loss (CBL) (using the Nadler and Gross formulae) and fall in Hb (percentage) from preoperative levels; and the incidence of thrombotic events and mortality up to 30 days. Results Groups were well matched in terms of patient demographics, comorbidities, preoperative anticoagulation use, injury types and surgical management. Intravenous TXA 1 g given at the beginning of surgery at the discretion of the operating team: 178 (49%) received TXA and 183 (51%) did not. The requirement for postoperative blood transfusion was significantly less in the TXA group: 15/178 (8.4%) compared to 58/183 (31.7%) (p \ 0.001; Chi square). TXA significantly reduced both the percentage fall in Hb (mean difference 4.3%, p \ 0.001) and the CBL (mean difference -222 ml, p \ 0.001). There was no difference in VTE (2 vs 1, p = 0.620) or other thrombotic events (2 vs 0, p = 0.244) between groups. Conclusion 1 g of intraoperative intravenous TXA during the surgical management of FFF was associated with reduced rate of transfusion, CBL and the percentage drop in HB. The use of TXA in this study was not randomised, so there could be un-quantifiable bias in the patient selection.

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