Acute Compartment Syndrome Due to Ruptured Baker Cyst After Nonsurgical Management of an Anterior Cruciate Ligament Tear : A Case Report
Aimee Lynn Schimizzi, Amir A. Jamali, Kenneth D. Herbst and Robert A. Pedowitz
The online version of this article can be found at:
can be found at: The American Journal of Sports Medicine Additional services and information for Acute Compartment Syndrome Due to Ruptured Baker Cyst After Nonsurgical Management of an Anterior Cruciate Ligament Tear A Case Report
Aimee Lynn Schimizzi, MD, Amir A. Jamali, MD, Kenneth D. Herbst, MD,and Robert A. Pedowitz,* MD, PhDFrom the Department of Orthopaedic Surgery, University of California, San Diego, San Diego,CaliforniaKeywords: compartment syndrome; Baker cyst; anterior cruciate ligament; fasciotomy, coagulopathy
Acute compartment syndrome is a clinical entity seen most
thrombophlebitis. That day, the patient underwent an MRI
often after extremity trauma. However, acute compartment
study, which confirmed the ACL tear in addition to a tear of
syndrome can also follow atraumatic bleeding into a closed
the posterior horn of the medial meniscus as well as a rup-
compartment.2,19,28,41 This case report describes an occur-
tured Baker cyst. He was treated with rest, elevation, warm
rence of acute compartment syndrome in the setting of bleed-
compresses, and scheduled doses of ibuprofen. The patient
ing from a ruptured Baker cyst. Five previous cases of acute
did well for the next 5 days. At that time, he had an acute
compartment syndrome in the setting of a ruptured12,23,31,38
increase in pain with increased swelling. A repeat ultrasound
or dissecting16 Baker cyst have been reported. This article
was negative for DVT. Compartment pressures were meas-
highlights a sixth case and emphasizes the importance of
ured and ranged between 15 and 20 mm Hg. A diagnosis of
potential contributing factors such as antithrombotic med-
possibly evolving acute compartment syndrome was made,
ications and mechanical factors such as leg curls and venous
and a venous compression device was placed on the foot
(Plexipulse, NuTech, San Antonio, Tex) to assist with venousreturn and decrease swelling. The patient was dischargedhome with this device. He came to the emergency depart-
ment 6 hours later with markedly increased swelling andtense compartments.
A 49-year-old man was initially evaluated with a 1-month his-
The patient’s medical history was significant for Gilbert
tory of a ruptured left ACL. He was treated with activity mod-
syndrome, benign prostatic hypertrophy, and depression.
ification and gradual range of motion restoration. He began
He had no history of coagulation or bleeding problems.
working aggressively on hamstring strengthening exercises
Routine medications included fluoxetine (Prozac) 10 mg
using prone leg curls with a roller that contacted on the prox-
imal posterior calf. Three weeks later, he came to the clinic
Physical examination revealed a healthy-appearing man
with increased left leg pain and swelling. Examination at that
in moderate pain. On musculoskeletal examination of the
time revealed pain with passive toe dorsiflexion (Homans
left knee, there were posterior fullness, tense swelling of all
sign). A duplex ultrasound revealed no evidence of deep
lower leg compartments, and increased pain with passive
venous thrombosis (DVT). He was diagnosed with superficial
flexion and extension of the left ankle. Dorsalis pedis andposterior tibial artery pulses were palpable. On neurologicexamination of the affected extremity, there was slightly
*Address correspondence to Robert A. Pedowitz, MD, PhD,
decreased sensation to light touch in the deep peroneal
Professor, Department of Orthopedics (8894), University of California,San Diego, 350 Dickinson Street, San Diego, CA 92103-8894 (e-mail:
nerve distribution. Compartment pressures were as follows:
superficial posterior, 78 mm Hg; deep posterior, 69 mm Hg;
No potential conflict of interest declared.
lateral, 79 mm Hg; and anterior, 78 mm Hg—confirming adiagnosis of acute compartment syndrome.
The American Journal of Sports Medicine, Vol. 34, No. 4
Radiographs of the left lower extremity were notable for
DOI: 10.1177/0363546505284184 2006 American Orthopaedic Society for Sports Medicine
soft tissue swelling. Complete blood count showed a mildly
The American Journal of Sports Medicine
elevated white blood cell count, with a normal differential,
cyst, increasing the diagnostic difficulty.26 Five previous
normal hematocrit, and normal platelets. The patient’s
cases of a ruptured Baker cyst leading to compartment syn-
bleeding time was elevated to 17.5 minutes, the prothrom-
drome have been reported in the literature.12,16,23,31,38
bin time was 10.8 minutes, and the partial thromboplastin
Acute compartment syndrome is most commonly associ-
time was 26.3 minutes. The patient was taken emergently
ated with extremity trauma. However, acute compartment
to the operating room and underwent 4-compartment fas-
syndromes induced by medication or concurrent disease-
ciotomy. At the time of surgery, the muscle appeared viable
induced bleeding have been reported in the litera-
and had no evidence of necrosis. After the fascial releases,
ture.4,12,19,23,28,31,38,41 The medications most commonly
intramuscular pressures were below 20 mm Hg in all com-
implicated are aspirin, warfarin, and heparin.2,4,19,41 Anouchi
partments. The wound was carefully inspected, and no
et al2 reported misdiagnosis of rupture of the medial head of
active bleeding was noted from either the skin edges or the
the gastrocnemius, “tennis leg,” treated with heparin for
deeper tissues. The skin edges were reapproximated using
suspected DVT with progression to compartment syndrome.
vessel loops and staples. The patient was admitted and
Our patient had been treated with the nonsteroidal anti-
started on intravenous antibiotics. His pain was markedly
inflammatory drug (NSAID) ibuprofen. The NSAIDs are fre-
improved postoperatively. His numbness also gradually
quently used medications with approximately 60 million
improved during the next several days.
prescriptions written per year in the United States.33 The
For the first 12 hours postoperatively, the wound
mechanism of action is inhibition of prostaglandin formation
remained relatively bloodless. During the next 12 hours, he
from arachidonic acid by inhibition of the enzyme cyclooxy-
had a significant increase in bleeding from the wound. A
genase (COX).33 Two isoenzymes of COX have been identified,
hematology consultation was obtained. During the first 4
COX-1 and COX-2. COX-1 appears to be a “housekeeping”
days of the admission, the patient had elevation of his
enzyme in multiple tissues such as the kidney, stomach, and
bleeding time to greater than 20 minutes and a drop in his
blood.33 Cox-2 appears to be the isoenzyme primarily respon-
hematocrit from 45% to 18.4%. With the recommendation of
sible for the inflammatory response.33 The NSAIDs inhibit
the hematology service, the patient was treated with trans-
platelet aggregation by inhibiting platelet production of
fusions of packed red blood cells and platelets. In addition,
thromboxane A2, which is required for platelet thrombus
his fluoxetine was discontinued. He was started on tran-
formation.6,22 The NSAIDs such as nabumetone (Relafen)
examic acid, a potent thrombolysis inhibitor.17 The patient’s
and etodolac (Lodine) have predominant activity at COX-2.
hematologic status improved with these interventions.
These medications appear to have improved clinical safety
On postoperative day 5, the patient underwent an MR
profiles with decreased gastric and hematologic complica-
angiogram to rule out an underlying arteriovenous malfor-
tions.10,22,25,36 In addition, in vitro studies have demonstrated
mation or aneurysm as a possible cause for the initial com-
that nabumetone has significantly less inhibition of platelet
partment syndrome. The MR angiogram showed a ruptured
thromboxane A2 synthesis than do naproxen and
Baker cyst and an adjacent hematoma. No arteriovenous
indomethacin.10,22 Newer COX-2 specific inhibitors, such as
malformation or aneurysms were noted.
celecoxib (Celebrex) and rofecoxib (Vioxx), have higher affini-
He was taken back to the operating room on postopera-
ties for COX-2 activity to provide a greater safety profile rel-
tive day 5 and underwent irrigation and debridement of his
ative to older NSAIDs.8,14,18,27 The patient in this case report
wounds. A large hematoma was revealed in the lateral com-
was taking ibuprofen, an older NSAID with both anti-inflam-
partment wound. This hematoma was debrided and sent for
bacteriology culture, which had negative results. A minimal
In addition to ibuprofen, the patient was taking fluoxe-
amount of superficial muscle appeared nonviable and was
tine. Fluoxetine (Prozac) is an antidepressant medication
debrided. The underlying muscle appeared normal and was
that inhibits central nervous system neuronal uptake of
contractile. All wounds were closed.
serotonin.21,29,30 It is metabolized through the liver to inac-
After complete healing of the skin incisions, the patient
tive metabolites, which undergo renal clearance. According
returned to a progressive rehabilitation program. He elected
to the Physicians Desk Reference,32 increased bleeding time,
not to undergo an ACL reconstruction. He eventually returned
anemia, ecchymosis, thrombocytopenia, thrombocythemia,
to all of his activities, including expert snow skiing and long-
petechiae, purpura, and other blood dyscrasias have been
reported as rare side effects of fluoxetine. Increased bleed-ing has been reported in cases of coadministration with
warfarin secondary to the inhibition of cytochrome P450.9,11However, in the literature, there are multiple reports of
Common diagnostic dilemmas involve the distinction
bleeding complications and bruising as a result of the use
between a ruptured Baker cyst and thrombophlebitis, as
of fluoxetine without concurrent use of antithrom-
both syndromes present with extremity swelling, pain, and
botics.3,21,30,37,42 In addition, reversible bleeding time pro-
pain with passive toe dorsiflexion (Homans sign).7,20
longation has been reported with fluoxetine use.21 Despite
Misdiagnosis of a ruptured Baker cyst as thrombophlebitis
these reports, no studies have proven fluoxetine causes
may lead to nonindicated anticoagulation with progression
bleeding dyscrasias. Several small prospective studies have
to compartment syndrome.7,12,19,20,31,41 Concurrent popliteal
failed to show significant hematologic changes from this
vein thrombosis can also occur along with a ruptured Baker
drug.1,5,24 These studies had small sample sizes (≤10 subjects)
and short follow-up (4 weeks of treatment). Because the
9. Claire RJ, Servis ME, Cram DL Jr. Potential interaction between warfarin
functional effect of fluoxetine on inhibition of platelet
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