Did Continuous Femoral and Sciatic Nerve Block Obscure the Diagnosis or Delay the Treatment of Acute Lower Leg Compartment Syndrome? A Case Report

Abstract

Despite concerns of masking pain that may be secondary to compartment syndrome, this case demonstrates that compartment syndrome can be diagnosed in the presence of effective regional anesthesia. Careful clinical evaluation coupled with a high index of suspicion is essential in the timely diagnosis and effective treatment of compartment syndrome.

Acute compartment syndrome risk in fracture fixation with regional blocks

“…On the contrary, Cometa et al 14 described a patient who developed pain in the lower extremity after undergoing proximal tibial and distal femoral osteotomies under cover of continuous femoral and sciatic nerve blocks, which were then changed to oral analgaesia. The patient developed pain on passive ankle dorsiflexion.…”

Pain Control in Acute Trauma

“…In the series four patients developed compartment syndrome, and in none of those four was the diagnosis masked or delayed by the neuraxial block [69]. Other reports of compartment syndrome in the presence of regional block describe cases in which diagnosis may or may not have been delayed [71][72][73]. One report blamed the delayed diagnosis of an anterior lower leg compartment syndrome on the presence of a femoral nerve block even though a femoral block would not at all affect sensation in the affected area [70].…”

Regional Anesthesia for the Trauma Patient

“…We would recommend avoiding longlasting dense blockade, using minimally effective infusions, and promptly addressing insensate limbs by withholding infusions until pinprick sensation returns. Perhaps even more importantly is a high level of vigilance as was exhibited by Cometa et al [Cometa et al, 2011] and close cooperation between the orthopedic surgeons and anesthesiologists involved. Using RA in these patients should only be considered in centers with a willingness to dedicate resources to the close monitoring of these patients and with caregivers who are acutely aware of the risks involved.…”

“…Little distinction is made between a limb in which a patient has analgesia but still can sense a pinprick exam, and one that is completely insensate. A recent case report by Cometa illustrated a scenario of a patient with an initially good analgesic block who experienced increasing pain as he developed ACS [Cometa et al, 2011].Because of the prompt recognition of this increasing pain by the anesthesiologists involved, the patient underwent a timely and limb-saving fasciotomy. Although no clear-cut evidence exists to support it, most experts suspect that somewhere on a continuum of density of nerve blockade lies the "danger zone" of sensory blockade in which we are at risk of masking the symptoms of ACS.…”