Ankle Injury - Weekend Warrior

HISTORY: A 38 year-old female with no past medical history presented to the ED for right ankle pain for the past three days after she twisted her ankle while wearing high heels. Her ankle pain began getting worse two days after the initial injury. She had visited urgent care and another outside hospital with negative x-rays for fracture and ultrasound for DVT. She was diagnosed with an ankle sprain and discharged home from the ED. Two days later, she returns to the ED for worsening swelling, pain, numbness, tingling of her right foot and calf. Her pain is now a 10/10 and has difficulty bearing weight. PHYSICAL EXAMINATION: Right Lower Extremity: + swelling present with firm but compressible compartments. Has comparable tension in the contralateral leg. No pain with passive stretch of toes or ankle. EHL/FHL 5/5, ankle dorsiflexion 3/5, 4-/5 ankle plantarflexion. Palpable DP pulse. DIFFERENTIAL DIAGNOSIS: Anterior Talofibular Ligament sprain. Compartment syndrome. Superficial fibular nerve entrapment. TEST AND RESULTS: Right X-Ray Tibia/Fibula 2 View: no acute bony abnormality. CTA Right Lower Extremity: no arterial occlusion in right thigh or calf. No acute osseous abnormality. Calf subcutaneous edema with poorly defined pretibial fluid but no encapsulated fluid collection to indicate abscess, and no soft tissue gas or mass. MRI Right Lower Extremity: lateral compartment enlargement and signal changes with perifascial edema highly suggestive of acute compartment syndrome of the lateral compartment of the leg. Creatine Kinase 10,086 on presentation, normalized during admission. Isolated AST elevation presented at 63, peak at 199. FINAL WORKING DIAGNOSIS: Compartment syndrome of right lateral compartment of the leg and resultant rhabdomyolysis TREATMENT AND OUTCOMES: 1. Underwent decompressive fasciotomy of lateral compartment with questionable viable muscle. Muscle was dusky and non-reactive to stimulation in the OR. Non-weight bearing and wound vac in place on discharge. 2. Follow-up with PCP and orthopedics post-discharge. Muscles healing and becoming viable. Has 4-/5 strength with ankle dorsiflexion, digital dorsiflexion and plantarflexion. 4+/5 strength with ankle plantarflexion. 3. Plastic surgery follow-up for wound care and eschar removal. No plans for muscle debridement as the wound is healing well.