Case reports 203

Discussion Superficial posterior compartment syndromes are very rare. Clinically, diagnosis can be difficult because the signs and symptoms are less obvious than those of the anterior or deep posterior compartments.

This case illustrates the importance of an awareness of this condition; we know of several similar cases where a torn muscle has been misdiagnosed as a deep vein thrombosis and the patient has been anticoagulated. This has caused further bleeding from the muscle giving rise to increased compartment pressure.

This report serves as a good illustration that the compart- ments act as individual units and that pressure is not transmitted between them.

Barnes M. R., Gibson M. J., Scott I. et al. (1985) A technique for the long-term measurement of intra-compartmental pressure in the lower leg. J. Biomed. Eng. 7, 35.

Blandy J. P. and Fuller R. (I957) March gangrene. Ischaemic myositis of the leg muscles from exercise. J. Bone Joint Surg. 39B, 679.

Kirby N. G. (/970) Exercise ischaemia in the fascial compartment of soleus. Report of a case. ]. Bone]oint Surg. 52B, 738.

Mubarak S. J., Owen C. A., Garfin S. et al. (1978) Acute exertional superfidal posterior compartment syndrome. Am. ]. Sports Med. 6, 287.

Paper accepted 30 August 1991.

References Allen M. J., Stifling A. J., Crawshaw C. V. et al. (i985)

Intracompartmental pressure monitoring of leg injuries. An aid to management. J. Bone Joint Surg. 67B, 53.

Requests for reprints should be Mdressed to: M. R. Barnes, Medical Physics Department, Leicester Royal Infirmary, Leicester LE1 5WW, UK.

Late presentation of a ruptured iliac aneurysm to a trauma department

A. J. Kelly, A. H. Davies and J. Collin University of Oxford, Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK

Introduction The clinical diagnosis of a ruptured abdominal aortic aneurysm can be difficult. Atypical presentations tend to delay diagnosis while inappropriate investigations are per- formed. Any delay is associated with a higher mortality after surgical repair (Mansfield and Gilling-Smith, 1990). Many atypical presentations have been described previously (Giliffiltan et al., 1986; Mansfield and Gilling-Smith, 1990).

We report a late pi'esentation of a ruptured aortoiliac aneurysm with pain in the hip and extensive lower limb bruising initially attributed to a fall.

Case report A 70-year-old man presented to the accident service with a 7 day history of pain in his buttock and hip following a fall. He had stopped smoking t5 years previously and was taking oxprenolol for hypertension.

On examination he was tender over the right ischial tuberosity with a large bruise of the buttock and posterior thigh extending to mid-calf (FigureD. Pulse was 80/min and blood pressure 130/80 mmHg. A non-tender pulsatile abdominal mass was noted in the epigastrium. The right hip had a good range of movement and was painful only on full flexion.

A plain radiograph of the pelvis revealed no bony injury, but bilateral eggshell calcification in aneurysmal common iliac arteries was evident. A computerized axial tomographic (CAT) scan confirmed an aneurysm of the infrarenal aorta and both common iliac arteries. The right common lilac artery was dilated to 8 cm

© 1992 Butterworth-Heinemann Ltd 0020-1383/92/030203-02

with surrounding haematoma. At operation the diagnosis of ruptured right common iliac aneurysm was confirmed and a large haematoma was present in the pelvis. The aorta and left common iliac artery were also aneurysmal and an aortobiextemal lilac artery graft was performed. Throughout the operation there was constant oozing from all dissected surfaces and the blood showed no tendency to clot. Postoperatively he continued to be hypo- volaemic despite massive transfusion and inotropic support. A second laparotomy 24h later failed to arrest the continuing haemorrhage from all dissected tissues and the patient died 2 days later.

Discussion Aneurysms of the lilac arteries usually occur in association with aneurysms of the abdominal aorta (Mansfield and

Figure 1. Extensive haematoma on the lateral aspect of the patient's right lower limb.

204 Injury: the British Journal of Accident Surgery (1992) Vol. 23/No. 3

Gilling-Smith, 1990). Rupture sometimes presents with unusual symptoms which tend to delay diagnosis and definitive surgery. Compression of surrounding structures may cause genito-urinary symptoms, iliofemoral venous thrombosis or neurapraxia of the sciatic or femoral nerves. Erosion of an aneurysm through the greater sciatic notch has been recorded as presenting as a pulsatile buttock swelling (Gilifillan et al., 1986; Mansfield and Gilling-Smith, 1990).

External bruising is a late sign of aneurysm rupture, but a 7 day delay, as in this case, is exceptional, since most ruptures would have proven fatal with such a long time lapse. Leaking aneurysms have previously been described as a cause of Grey-Tumer's and Cullen's signs, as well as bruising in the scrotum (Ratzan et al., 1987), perianal region (Tamvakopoulos et al., 1969) and over the subsartorial canal (Rob and Williams, 1961). In this case, there was extensive bruising in the buttock, thigh and calf, but none over the extensor compartment of the thigh (Figure I), suggesting that the haematoma had tracked through the greater sciatic notch. Pain and bruising are common after falls but, as in this case, the fall may be caused by hypovolaemia from blood loss or other systemic disease. A leaking aneurysm should always be considered as a cause of any bruising between the umbilicus and knee because the diagnosis relies on a high degree of clinical suspicion. Thorough clinical examination of the abdomen is mandatory, although isolated iliac aneurysms are often not palpable during abdominal exam- ination; however, they can sometimes be detected on rectal examination. A plain lateral radiograph of the abdomen shows eggshell calcification in up to 70 per cent of abdominal aortic aneurysms (Tamvakopoulos et al., 1969); the routine investigation of choice is an ultrasound scan,

with a CAT scan being used in cases where the result of the ultrasound scan is uncertain. Without surgery, rupture of an iliac artery aneurysm carries a mortality of 100 per cent and any delay adversely affects the outcome of surgical repair (Mansfield and Gilling-Smith, 1990), as this case demon- strates well.

References

Gilifillan I v Fell G., King B. et al. (1986) Unusual isolated iliac artery aneurysm. Br. J. $urg. 73, 375.

Mansfield A. O. and Gilling-Smith G. L. (1990) Unusual presenta- tions of aneurysms. In: Greenhalgh R. M. and Mannick J. A. (eds). The Cause and Management of Aneurysm. London: W. B. Saunders, 105.

Ratzan R. M., Donaldson M. C., Foster J. H. et al. (1987) The blue scrotal sign of Bryant: a diagnostic clue to ruptured abdominal aortic aneurysm. J. Emerg. Med. 5,323.

Rob C. G. and Williams J. P. (196I) The diagnosis of aneurysms of the abdominal aorta. J. Cardiovasc. Surg. 2, 55.

Tamvakopoulos S. K., Corvese W. P. and Vargas L. L. (1969) Perianal haematoma - a sign of leakage after rupture of aortic aneurysm. N. Eng]. J. Mled. 280, 548.

Paper accepted 24 September 1991.

Requests for reprints should be addressed to: Mr J. Collin, University of Oxford, Nuffield Department of Surgery, John Radcliffe Hospital, Oxford OX3 9DU, UK.

The true 'boxer's fracture'?

S. Cavanagh St Mary's Hospital, London, UK

Introduction Fractures of the trapezium are rare, representing approxi- mately 3.5 per cent of all fractures of the carpus (Borgeskov et al., 1966). Of the reported fractures only 20 per cent have been vertical.

Case report A vertical fracture of this bone was sustained by a 28-year-old professional boxer, the British cruiserweight champion, during the course of a fight (Figure 1). Radiographs and physical examination failed to show evidence of subluxation of the first metacarpal and a short period of immobilization in a plaster cast was therefore advised. He declined this, however, in view of his imminent Commonwealth title fight.

Discuss ion The mechanism of injury is controversial. K6hler (1928) concluded that isolated fractures of the trapezium were particularly rare and almost impossible to reproduce experi- mentally. Kindle's (1910) cadaveric studies led him to

© 1992 Butterworth-Heinemann Ltd 0020-1383/92/030204-02

Figure 1. Vertical fracture of the carpus.