Delayed Onset of Acute Compartment Syndrome of Lower Leg and Foot after Crush Injury. Case Report

This case report presents a 25-year-old man who sustained a crush injury to the right lower limb at the workplace due to compression by a car wheel hub. Initial examination revealed marked swelling of the lower leg and midfoot with preserved sensation and peripheral perfusion. Radiographs demonstrated a bimalleolar ankle fracture and multiple foot fractures. Approximately 5 hours after admission, the patient developed rapidly increasing pain, pallor and cooling of the foot, absence of the dorsalis pedis pulse, decreased toe sensation, and oxygen saturation of 80%. CT angiography showed absent flow in the distal segments of the anterior tibial and fibular arteries. An urgent fasciotomy of the lower leg and dorsal foot compartments was performed ten hours after injury using the shoelace technique, resulting in immediate restoration of perfusion and foot warmth. Sixteen days later, necrotic tissue was debrided, the defect was covered with a split-thickness skin graft (Thiersch technique), and the medial malleolus was stabilized with Kirschner wires. Wound healing was uneventful, with no signs of infection. This case highlights the dynamic and potentially misleading course of acute compartment syndrome and underscores the need for frequent clinical reassessment despite an initially reassuring presentation. Prompt diagnosis and immediate complete fasciotomy prevented irreversible complications.