S222 S290
Poster 285:
A Case Report of Season Ending Ankle Sprain: A Rare
Complication of Compartment Syndrome Following
an Inversion Ankle Injury
Justin A. Raper, MD (Albert Einstein Col of Med), Yuxi Chen, MD,
FAAPMR, Shayan Senthelal, MD
Disclosures:
Justin Raper: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 15-year-old male presented to the
emergency department 4 days after a left ankle inversion injury. He
had severe left leg pain, swelling, anterior and lateral shin tenderness,
numbness with decreased sensation in the superficial and deep pero-
neal nerve distribution, foot drop, and loss of ankle dorsiflexion and
eversion. Patient was treated conservatively with intravenous hydra-
tion. On follow-up with physiatry, a night-time foot splint was pre-
scribed. Two weeks later, the sensory deficit and weakness in left
ankle dorsiflexors and evertors persisted. At 3 months the left foot
drop resolved, while weakness of evertors, extensor hallucis longus,
and sensory deficit of the dorsal foot remained.
Setting:
University Hospital.
Results:
X-ray was negative for fracture, CK was 9360, ALT 90, and
AST 205 units/L. MRI showed proximal anterior and lateral compart-
ment muscle edema and hemorrhage. Lateral compartment pressure
was 8 mmHg. Electromyography and Nerve Conduction Study revealed
left superficial and deep peroneal nerve axonal neuropathy.
Discussion:
Acute compartment syndrome is a rare but serious cause
of lower extremity pain that is typically managed by removing
external pressure, analgesics, supplemental oxygen, and possible
fasciotomy. Potential complications include rhabdomyolysis, muscle
contractures, neuropathy, and paralysis. Best outcomes are obtained
when decompression is performed within 6 hours from onset of
symptoms, while 12 hours is associated with a poor chance for return
to normal function. This emphasizes the importance of early diag-
nosis and intervention. In this case, ankle sprain caused intramus-
cular hemorrhage that led to compartment syndrome. A notable
feature is the patient did not require fasciotomy and had favorable
recovery with conservative care.
Conclusions:
Inversion ankle sprain is a common problem encoun-
tered on a regular basis. Physicians should be aware that acute
compartment syndrome may occur following an inversion ankle injury
in the absence of a fracture. Early recognition and intervention are
critical for the best outcomes.
Level of Evidence:
Level V
Poster 286:
Pelvic Fractures Due to Osteomalacia Following Gastric
Bypass Surgery: A Case Report
Claire E. Finkel, MD (Univ of MO-Columbia), Sarah K. Hwang, MD,
FAAPMR
Disclosures:
Claire Finkel: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 39-year-old woman was referred to
the pelvic pain clinic for evaluation of her pelvic floor due to right
inguinal pain. She described a 2-year history of stabbing pain with
standing and ambulation that abated with rest. She had seen mul-
tiple providers for this pain with prior work-up including a nerve
conduction study and treatment with multiple nerve blocks without
relief. Medical history revealed Roux-en-Y gastric bypass surgery 12
years prior. Exam was significant for right hip flexor weakness and
pain with all maneuvers of the right hip. She had no levator spasm
on pelvic floor exam. Imaging revealed subacute fractures at the
right femoral diaphysis, left femoral neck, left superior and inferior
pubic rami, bilateral sacrum, and right metatarsals. Serum vitamin
D level was low at
<
13 ng/mL. Dual-energy X-ray absorptiometry
revealed Z-score of -4.1 at the right hip consistent with severe
osteoporosis. She was started on high-dose vitamin D and calcium
supplementation. The patient underwent intramedullary nailing of
the bilateral femoral fractures and percutaneous fixation of the
sacral fractures.
Setting:
Outpatient clinic.
Results:
On follow-up the patient was weight-bearing as tolerated
in the bilateral lower extremities and was ambulating with a
wheeled walker. Pain was greatly improved. She had completed
home health therapies and returned to work. Repeat vitamin D
level has been ordered to assess efficacy of oral vitamin D
supplementation.
Discussion:
Gastric bypass surgery places patients at risk for meta-
bolic disturbances from malabsorption. Extreme deficiencies can lead
to osteomalacia and place patients at risk for occult fractures. The
number of fractures and length of time to diagnosis despite seeking
medical care make this case unusual.
Conclusions:
Fractures must be included in the differential diagnosis
of the patient with pelvic pain, especially in patients at risk for
metabolic disturbance due to nutritional deficiencies.
Level of Evidence:
Level V
Poster 287:
Delayed Onset Tetraplegia Following Spinal Cord Injury:
A Case Report
Ketan Patel, Resident Physician (Nassau University Medical Center,
Anaheim, California, United States), Wendy Luo, MD, Brian P. Golden,
DO, Lyn D. Weiss, MD, Phillip G. Mendis, DO, Ajendra Sohal, MD
Disclosures:
Ketan Patel: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 23-year-old man with no prior med-
ical history presented to the emergency department unresponsive,
hypotensive, and bradycardic (Glasgow Coma Scale: 3). Two days
prior to admission, the patient had played football, where he
tackled an opposing player using his head and shoulder region
with a flexed neck, resulting in no immediate deficits. The next
day, he continued normal activities including attending work and
lifting weights at the gym, complaining only of neck stiffness. On
the day of admission, the patient was woken from sleep due to
excruciating neck pain associated with bilateral upper extremity
numbness and tingling. He then became unresponsive en route to
the hospital but regained consciousness following intubation,
pressor support, and atropine. Initial physical exam was notable
for flaccid tetraplegia, absent deep tendon reflexes throughout
and impaired pin prick and temperature over arms, but intact
over legs.
Setting:
Medical Intensive Care Unit.
Results:
MRI confirmed spinal cord contusion from C1-C4 resulting in
spinal cord shock. The patient was started on bedside physical and
occupational therapy. Prior to being discharged to an acute rehab
facility, the patient began to regain movement of distal lower
extremities.
Discussion:
The manifestations of spinal cord shock such as areflexia,
flaccid paralysis and autonomic dysfunction are typically observed
within seconds to minutes in the acute setting following spinal cord
injury. The culmination of these symptoms occurring in hours to days,
such as this case, has rarely been documented.
Conclusions:
Spinal cord shock is a debilitating and potentially deadly
insult following trauma to the spinal cord. It is imperative for physi-
cians to obtain a thorough history and physical exam, as presentation
of spinal shock following trauma may be delayed. Once a diagnosis is
made and the patient is medically optimized, immediate commence-
ment of a rehabilitation program can assist in functional improvement.
Level of Evidence:
Level V
S222
Abstracts / PM R 9 (2017) S131-S290