Working Diagnosis:
Acute Anterior (Volar) Compartment Syndrome (AACS)

Treatment:
The patient was taken to the operating room by orthopedic surgery where he underwent an emergent anterior (volar) compartment fasciotomy. A dusky appearance to the distal biceps muscle belly with extensive clotting was noted in the distal biceps region Case Photo #2 Case Photo #3 . Once fasciotomy was complete, the surgical site was left open for two days prior to closure.

Outcome:
Postoperative recovery was uncomplicated. Sensory symptoms resolved and motor strength returned over the next two days. On examination of the muscle belly two days later, a more natural coloration of the muscle had returned Case Photo #4 and the fasciotomy site was closed Case Photo #5 . The patient had no contractures or chronic pain and was able to return to a playoff game in his football season five weeks after surgery. He continues to do well today.

Author's Comments:
AACS is most commonly a sequela of elbow trauma, most commonly after supracondylar or distal humerus fractures. This case demonstrates the uncommon onset of AACS after a football blunt trauma without fracture or vascular damage. Compressive neuropathy developed from rising intracompartmental pressure. Although sports-related cases of acute anterior compartment syndrome have been described following various direct impact injuries, including an umpire struck by a baseball pitch, they have typically been characterized by a more gradual onset of symptoms. In contrast, the present case demonstrated rapid symptom progression requiring expedited diagnosis and management. Frequent re-examination is critical if pain escalates and negative neurovascular imaging does not rule out AACS. Compartment pressure testing is the gold standard for AACS diagnosis, although was foregone in the setting of high suspicion of the diagnosis and need for emergent OR intervention to ultimately salvage the limb.

Editor's Comments:
This case highlights the importance of serial clinical assessment following blunt elbow trauma, as acute compartment syndrome may evolve despite an initially benign examination and the absence of fracture or vascular injury. Worsening pain, increasing compartment tension, pain with passive stretch, and progressive neurologic deficits should prompt urgent orthopedic evaluation, even when pulses are preserved and vascular imaging is normal. Intracompartmental pressure measurement is a useful adjunct in the diagnosis of acute compartment syndrome, especially in uncertain cases. However, the diagnosis remains primarily clinical, and a high index of suspicion should prompt emergent fasciotomy without delaying treatment for confirmatory pressure testing. Timely recognition and surgical intervention are critical to preventing irreversible neuromuscular injury.

References:
1. Pasque CB, Hendrix RW. Forearm compartment syndrome after being struck by a baseball. Orthopedics. 1990;13(5):593-596.
Iwai M, Murase T, Tsubokawa N, et al. Forearm compartment syndrome due to muscle contusion in a golfer without fracture: a case report. J Orthop Sci. 2019;24(3):540-543.
2. Matsen FA III, Krugmire RB Jr. Compartmental syndromes in the forearm: early recognition and treatment. J Bone Joint Surg Am. 1977;59(3):384-387.
3. Mubarak SJ, Hargens AR. Acute compartment syndromes. Surg Clin North Am. 1983;63(3):539-565.
4. Heemskerk J, Kitslaar PJ. Acute compartment syndrome of the upper extremity: early recognition and treatment. Neth J Surg. 1988;40(1):15-19.

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