A 23-year-old heroin addict is brought to the ED after being found unconscious in an alley. The paramedics gave intravenous naloxone and he immediately awakened. He complains of severe pain in his left lower leg, but denies a groin injection. Physical examination shows that he is unable to dorsiflex his left big toe, and he has anterior tibial pain when you passively plantar flex. Sensation and both patellar and Achilles reflexes are equal bilaterally, and bilateral posterior tibial pulses are intact. Nonpitting leg edema consistent with chronic venous stasis disease involves both legs. You should now:
Consult orthopedic surgery for emergency management.
+Consult radiology for an arteriogram.
+Consult neurology for management of neuropathy.
+Obtain lumbar spine films to rule out an epidural abscess.
+Obtain a bilateral venogram to rule out DVT.
A compartment syndrome should be suspected in this patient with loss of muscle function of the anterior tibial compartment (extensor hallucis longus), pain with passive flexion of the muscles, and a history of being unconscious. Drug abusers may assume positions that lead to compromised blood flow and schema-induced muscle swelling. Pedal pulses are not necessarily affected. The findings are not compatible with a cord lesion. Acute DVT in this patient is unlikely and would not account for the muscle weakness. A “woody” consistency to the leg may be present, but is difficult to appreciate in patients with chronic venous insufficiency. Prompt diagnosis and surgical fasciotomy are essential to prevent muscle necrosis. Associated signs of infection would indicate a possible necrotizing fasciitis.