Table 1 Timeline of events following birth

1.5 hours

Returned to the postnatal ward following an emergency cesarean section; full sensation and movement were noted in both legs.

12 hours

Onset of pain and swelling in right lower leg.

14 hours

The postpartum woman complained of pain in her right shin. An obstetrics and gynecology assessment revealed extreme pain on mobilization and weight bearing in the lower right leg, with worsening pain upon movement over the tibialis anterior with plantar flexion. A physical examination revealed a decreased range of motion in the right foot and decreased extension of the right great toe. Minimal pitting edema was noted on the right foot, and capillary refill was normal in both feet. A small and very painful soft lump was palpable over the anterior midshin area of the right leg. Range of motion in both knees and ankles was normal, as were the lower limb reflexes and pedal pulses. No calf tenderness or skin changes were noted, and skin temperature was normal. Sensation was normal, and the postpartum woman was afebrile. The impression at the time was deemed to be muscle-related pain, and therefore she was commenced on analgesia and encouraged to mobilize and to elevate the leg on a pillow. A deep venous thrombosis was not considered at this stage, because there was no calf tenderness. A heat pack was applied to the lower right leg and antiembolism stockings were applied to both legs.

23 hours

Swelling in the right leg and foot had worsened, and the postpartum woman experienced a burning sensation along the muscle. By this stage, she was no longer able to bear weight.

28 hours

The antiembolism stockings were removed due to increased pain, and this resulted in sudden and extreme pain and further swelling in the right lower leg and foot. Assessment revealed that the right leg and foot were very swollen and the foot was curving inward and was painful to touch. The postpartum woman was unable to move her toes or lift her foot due to pain, and a review was conducted by the obstetrics and gynecology registrar.

By this stage, the woman was in extreme pain and reported constant throbbing in the leg. Examination revealed a decreased range of motion in the right foot; the right foot was markedly more swollen than the left; and the anterior right leg and anterior foot were very tender to touch. Pedal pulses were palpable, and perfusion to the toes was noted. The nodule over the anterior midshin remained palpable, and the skin now appeared red. There was no reported calf pain, and she remained afebrile. Cellulitis was diagnosed, and a blood sample collected at this time revealed deranged liver function test results. The woman was then commenced on intravenous antibiotics and enoxaparin sodium (Clexane; Sanofi-Aventis, Macquarie Park, Australia), an anticoagulant, prophylactically because she was now immobile. Subcutaneous morphine was administered with no effect, and the antiembolism stocking was unable to be reapplied to the right leg due to extreme pain. Six hours following this acute stage, the postpartum woman reported feeling more comfortable, and her right leg was less swollen and less tender; however, the limb remained red. An anesthetic review at this time excluded an epidural-related cause for the ongoing right great toe weakness.

Day 2

There was still visible swelling and worsening of pain after mobilizing; therefore, the patient remained on bedrest. Clexane was changed to a therapeutic dose, and analgesia was continued (Endone [oxycodone hydrochloride], Alphapharm Pty Ltd, Millers Park, Australia; Panadol [acetaminophen], GlaxoSmithKline Australia, Ermington, Australia; and Voltaren [diclofenac], GlaxoSmithKline Australia). Venous Doppler ultrasound was performed to exclude deep venous thrombosis, and the findings were unremarkable. The leg was more inflamed and reddened following the Doppler ultrasound, and the postpartum woman was now completely unable to bear weight on the right leg.

Day 3

Some improvement in pain and redness was noted, but weakness of the right great toe remained. The postpartum woman was still unable to hyperflex the right great toe, and the results of her liver function tests were more deranged. Clexane was reverted to a prophylactic dose, and antibiotics were changed again; the woman remained afebrile. A second anesthetic examination confirmed ongoing weakness of the great toe, and sensation was intact. The differential diagnosis at this stage included possible neurological problems, cellulitis, or gout.

Day 4

Skin redness had started to improve, but mobility was limited due to pain. Neurological symptoms remained unchanged, and some reduction in plantar adduction was noted. Upon examination by a neurologist, the leg was tender and swollen below the knee. There was severe pain upon examination, and the neurologist was unable to check right inversion due to the pain. Sensation was found to be decreased to the peroneal region. The differential diagnoses queried by the neurologist included right peroneal nerve palsy, pressure effect, compartment syndrome, and cellulitis. The postpartum woman was referred to the infectious diseases team for management of cellulitis and for a vascular opinion regarding possible compartment syndrome. Antibiotics were changed again, and a surgical review deemed that symptoms were not diagnostic of compartment syndrome.

Day 4 (95 hours)

By this stage, the postpartum woman reported numbness between the right great toe and the second toe, a new symptom.

Day 5

An examination revealed increased redness and loss of sensation over the first web space of the right foot. The postpartum woman continued to complain of increased pain. The diagnosis at the time was worsening cellulitis and worsening of neurological symptoms secondary to the worsening cellulitis. Antibiotics were changed again, and the woman was continued on Clexane.

Day 7

Symptoms of cellulitis remained unchanged. Antibiotics were changed again in consultation with the infectious diseases team.

Day 8

Neurological symptoms remained unresolved, so a neurologist was consulted again.

Day 10

Magnetic resonance imaging was performed, and the findings were consistent with acute compartment syndrome.

Day 11

Orthopedic consultation was obtained. There were clinical features of a compartment syndrome affecting the anterior compartment of the right lower leg. An examination showed foot drop and paresthesia along the deep and superficial peroneal nerves. Pain had moderated by that time, but there was still evident swelling of the anterior compartment with associated tenderness and some dusky erythema. There was no active contraction of the great toe extensor, and there was reduced extensor function of the lesser toes and the tibialis anterior. The anterior compartment pressure was measured as 19 mmHg, and pressure in the peroneal compartment was 23 mmHg. Following consultation with other orthopedic and vascular surgeons at a tertiary referral hospital, the compartment syndrome was managed nonsurgically, given that 11 days had elapsed since the onset of symptoms and a fasciotomy at this stage would not prevent any further damage.

Days 11–15

The woman was commenced on physiotherapy and fitted with a foot drop splint and a rollator frame to assist with mobilization. Intravenous antibiotics were continued until discharge from the postnatal ward.

Day 15

The woman was discharged to home on a course of oral antibiotics.