Case Situation A 54-year-old man was admitted to our hospital for treatment of compartment syndrome of the left lower extremity. He gave a history of sustaining a puncture wound from an injection of equine steroid to his left medial thigh. He immediately felt pain and noted pallor in the left lower leg, and the extremity soon became edematous. He went to his local emergency department, was treated with an oral steroid dosepak, and was released. The pain and edema increased during the next 2 days, and the patient came to our emergency department with mottling of the left lower leg, severe pain, edema, and numbness of his toes. The patient’s dorsalis pedis and posterior tibial pulses were not palpable but were audible with a Doppler. The Doppler ultrasound showed no deep venous thrombosis or arterial injury but did show compression of the popliteal and tibial veins because of severe swelling of the left calf. The arterial component of the Doppler ultrasound was not completed because of severe leg pain. The anterior lateral compartment pressure was 100 mm Hg, and the medial compartment pressure was 99 mm Hg. Pressures from 40 to 80 mm Hg sustained for 12 hours or more can cause significant muscle necrosis and permanent neurologic changes.1 The patient’s serum glutamate oxaloacetate transaminase level was 1386 (normal, 0-37), his serum glutamate pyruvate transaminase level was 590 (normal, 0-40), and his white blood cell count was 21,160 (normal, 3.5-11,000). The patient was given cefazolin (Kefzol), 1 gm intravenously every 8 hours for 6 doses, and intravenous morphine sulfate for pain management. Phillips1 defined the pathophysiology of compartment syndrome as an insult to normal local tissue homeostasis that results in increased tissue pressure, decreased capillary blood flow, and local tissue necrosis caused by oxygen deprivation. Physical signs of acute compartment syndrome are extreme pain out of proportion to the injury, pallor of the extremity, and paresthesia. Passive stretch of the muscle causes increased pain. Muscle weakness, paralysis, and an absent extremity pulse are late findings. When compartmental pressures are greater than 30 mm Hg in the presence of clinical findings, the recommended treatment is to perform a fasciotomy to decompress the leg compartments. The prognosis is good when a fasciotomy is performed 25 to 30 hours after onset. After the third or fourth day, a fasciotomy may be contraindicated because severe infections can occur in the necrotic muscle.1 The patient underwent medial and lateral fasciotomies of the left lower extremity and debridement of necrotic tissue. The orthopedic surgeon ordered that the wounds be packed with dressings moistened with 0.25% Dakin’s solution. The dressings were changed at least every 4 hours because of copious amounts of serosanguineous drainage. The patient’s bed linens were often saturated. The dressing changes were painful, and each change took 30 minutes. Foot drop was already present, and a splint was used for treatment. A plastic surgeon and the WOC nurse were consulted for wound care recommendations. Linda Wessel, BSN, RN, CWOCN: Following debridement by the plastic surgeon, the medial and lateral wounds measured 32 cm and 30 cm in length and 8 cm in width. Extensive ecchymosis was present in the periwound tissue, and tendons were exposed in both wounds (Figures 1 and 2). Because of the copious amount of serosanguineous drainage, the need to reduce edema, and the need to promote granulation tissue, it was decided to treat the wound with the Vacuum Assisted Closure (VAC) system (Kinetic Concepts, Inc, San Antonio, Tex). The VAC system uses a sterile foam dressing connected to a suction pump that applies negative pressure to the wound. The negative pressure removes wound debris, fluid, and bacteria. It increases tissue perfusion, thus promoting granulation of the tissue.2 The foam dressing is placed in the wound and secured with an occlusive film dressing that decreases bacterial contamination.3 Figure 3 shows the medial calf wound with the VAC dressing in place. The suction canisters are either stationary or portable and can be handled easily by the nursing staff. Pain medication was administered prior to the VAC dressing change if needed. Supplies listed in the Box were used. Universal precautions were followed. The dressing tubing was clamped and disconnected from the canister tubing. Allkare Adhesive Removal Wipes (ConvaTec, Princeton, NJ) were used to help loosen the film dressing. Sterile normal saline solution was Linda C. Wessel, BSN, RN, CWOCN, is Patient Educator and Consultant for the Wound Care and Hyperbaric Medicine Center, Southeast Missouri Hospital, Cape Girardeau, Missouri.