Simulation of compartment syndrome by rupture of the deep femoral artery from blunt trauma

Life-threatening hemorrhage of the femoral vasculature from a blunt injury to the thigh without femoral fracture has not been emphasized in the medical literature. Two cases of massive hemorrhage from the deep femoral system resulted from blunt injury to the thigh without femoral fracture. In the first case, a diagnosis of compartment syndrome was based on muscle swelling from the blunt trauma. A fasciotomy uncovered life-threatening bleeding. In the second case, which had a similar history and clinical symptoms, a vascular injury was suspected and an arteriogram was done. Disruption of the deep femoral arterial system was detected, and fluoroscopic embolization controlled the bleeding. A routine fasciotomy was then done. Both patients appeared clinically to have a thigh compartment syndrome, presumably based on injury from the crushed muscle. They both had normal arterial pulsations distal to the injured thigh. The only feature that suggested a vascular injury was a need for transfusion for hemodynamic support in excess of apparent blood loss. Arteriography, with embolization if necessary, is advised for all cases of suspected thigh compartment syndrome in which there is an unexplained need for hemodynamic support by transfusion.     

Compartment syndrome of the thigh as a complication of anticoagulant therapy in a patient with a left ventricular assist device (Berlin Heart)

A nontraumatic case of compartment syndrome of the thigh in a patient on anticoagulant therapy for a left ventricular assist device (LVAD) is reported. A 51-year-old man was on low-molecular-weight heparin (LMWH) anticoagulation and antiplatelet drugs for his LVAD, when he had a spontaneous-onset compartment syndrome of the posterior compartment of the left thigh, which was treated with urgent fasciotomy. Although compartment syndromes in the thigh are rare and mostly traumatic in origin, all clinicians must maintain a high degree of suspicion; moreover, although most often bleeding associated with LMWH is minor, occasionally it results in a major bleed resulting in limb-threatening conditions such as a compartment syndrome.     

Delayed presentation of acute compartment syndrome after contusion of the thigh

Acute compartment syndrome has been described as a result of thigh contusion in several contact sports, and emergent fasciotomy has routinely been recommended. However, recent data suggest that thigh contusions in athletes presenting with isolated elevation of compartment pressures in the absence of neurovascular deficits may be treated expectantly. We describe a case of anterior thigh contusion, which initially presented with isolated compartmental hypertension without neurovascular symptoms. Under nonoperative treatment the patient developed delayed acute compartment syndrome from persistent muscular hemorrhage ten days after the initial trauma, requiring operative treatment. This case demonstrates that expanding hematoma formation may result in delayed increase of intramuscular pressures and compromise of myoneural perfusion in patients with severe thigh contusions. Early evacuation of the hematoma may help to prevent late development of compartment syndrome and reduce the risk for long-term complications.     

Acute Compartment Syndrome of the Thigh with Sciatic Nerve Palsy after Femoral Fractures

Acute compartment syndromes of the thigh are rare and have been infrequently reported in the literature. They occur with greatest frequency in association with femoral fractures. Patients who sustained multiple trauma have an increased susceptibility to the development of compartment syndrome of the thigh, and compartment syndromes are often overlooked in these cases. A compartment syndrome in a cooperative patient can be diagnosed clinically, but it presents a special challenge if the patient is multiply injured and unable to cooperate with the physical examination. Left unrecognized, compartment syndromes of the thigh can result in permanent damage to muscle and nerve in that compartment. Early diagnosis through a high index of suspicion and measurement of intracompartmental pressure in each compartment is mandatory. Intraoperative measurement of compartment pressure is recommended in cases of impending compartment syndrome. Immediate fasciotomy is indicated to provide the optimum chance of recovery and to prevent microvascular compromise and necrosis of tissue. We present 3 cases of multiply injured patients in which sciatic nerve palsy followed fracture of the ipsilateral femur und compartment syndrome of the thigh. We found that the extent of myoneural necrosis seems to be dependent on the duration and magnitude of the elevated compartment pressure. A comprehensive review of the literature about compartment syndromes of the thigh is also presented.     

Compartment syndrome of the buttock following a total hip arthroplasty

An elevation of the interstitial pressure in a closed osseofascial compartment results in compartment syndrome. This may be caused by a decrease in compartment volume or an increase in compartment contents. The gluteal compartment syndrome is rare. Because the gluteal region has a large volume, this compartment requires a massive increase in content to cause a compartment syndrome. Also, this compartment blends anatomically with the muscles of the thigh, allowing extravasation of blood outside the compartmental envelope. This case report is of a patient whose medial circumflex femoral artery was severed during a total hip arthroplasty through a posterior approach leading to compartment syndrome of the buttock. Although this clinical presentation has not been described as compartment syndrome, one similar presentation was described in the literature.     

Incipient compartment syndrome of the thigh following total knee arthroplasty

Compartment syndrome of the thigh is in itself a rarity because of the large size of the compartment and the relatively high compliance of the thigh which allows accommodation to volume changes due to hematoma or tissue edema. Most cases have been reported in association with impact trauma to the lower extremity or in association with crush syndrome. A previously unrecognized complication of total knee arthroplasty where an incipient compartment syndrome developed in the thigh extensor compartment is reported.     

Acute Anterior Thigh Compartment Syndrome Revisited: A Case Report and Review of Literature

Abstract We present a rare case of acute anterior compartment syndrome of the thigh in a rugby player with no history of trauma during the game. Decompressive fasciotomy with subsequent closure of the wound resulted in good outcome. Acute compartment syndrome of the thigh should be suspected following vigorous exercise and fasciotomy is to be performed on urgent basis.     

Compartment syndrome of the thigh after blunt trauma: a complication not to be ignored

We report a case of anterior thigh compartment syndrome, which occurred after man’s thigh was bruised after flipping repeatedly over his bike and being hit by the frame of the bike nearly at around 6 pm. The next day at 1:30 am, he was admitted to the hospital. The initial presentation was a hematoma, and the patient was kept in bed with local cooling. The compartment syndrome of the thigh (CST) diagnosis was made around 6:00 pm when the level of pain was interpreted as disproportionate to the treated lesion; anterior compartment pressure measure was 84 mmHg. A compartment fasciotomy was performed. It is difficult to diagnose a CST in case of muscular contusion as the latter causes symptoms that are similar to CST. A conservative treatment without fasciotomy was carried out by several authors, especially in sportsmen showing a CST following contusion. This conservative treatment implies close monitoring of intramuscular pressures and adjuvant measures (bed rest, holding the thigh at the heart level and oxygenotherapy).     

Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries

The reason for the described clinical variability of acute compartment syndrome of the thigh, with high morbidity and mortality in some patients and an uncomplicated clinical course in others, is not known. To better define the clinical spectrum and factors determining the clinical course of this rare clinical entity, we did a retrospective multicenter study of 28 patients with 29 thigh compartment syndromes. The leading cause of acute thigh compartment syndrome was blunt trauma from motor vehicle accidents (46%) or contusion (39%). Pain with passive motion was present in all patients who were conscious, followed by paresthesia (60%), and paralysis (42%). The anterior compartment was involved most frequently with mean compartment pressure of 58 +/- 3 mm Hg. Myonecrosis, sepsis, and need for skin grafting were observed more frequently in patients with ipsilateral femur fracture. Only 7% of patients with isolated thigh compartment syndromes had short-term complications compared with 57% of patients with ipsilateral femur fractures. The incidence of complications correlated with the time to fasciotomy. Mortality was limited to patients with high injury severity scores. The clinical spectrum of thigh compartment syndrome is comparable with that of other compartment syndromes and its clinical course is determined by its associated injuries.     

Das Kompartmentsyndrom am Oberschenkel mit Ischiadikusparese

Acute compartment syndrome of the thigh has been infrequently reported in the literature. Closed femoral fractures and blunt soft tissue trauma are the main causes of this injury. The multiple injured patient in this case report developed a compartment syndrome of the thigh after intramedullary nailing of a comminuted fracture of the femur. Fasciotomy was performed two days after surgery because of extense swelling of the thigh in the ventilated and sedated patient. Sciatic and femoral nerve palsy was recognized after extubation of the patient nine days after the injury. During the following weeks the paresis of the femoral nerve recovered but neither motor nor sensory function of the sciatic nerve could be demonstrated. Therefore an operative revision of the sciatic nerve was performed eighteen weeks after trauma. No direct nerve injury could be detected but there were adhesions around the nerve as a sign of compression neuropathy caused by the compartment syndrome. The tibial component of the sciatic nerve showed a complete recovery within the next months but there was a persisting peroneal nerve palsy. CONCLUSION: Early clinical symptoms of a compartment syndrome like pain, paresthesia and paresis can not be ascertained in a ventilated and sedated patient. Tense swelling of the muscles is often the only detectable sign. Frequent measurements of compartment pressure should be done in these patients. We suggest early decompressive fasciotomy because the morbidity caused by fasciotomy in a borderline compartment syndrome is far outweighed by the morbidity that accompanies an undiagnosed untreated compartment syndrome with possible nerve palsy.     

Acute Gluteal and Thigh Compartment Syndrome following Pelvic Fracture and Superior Gluteal Artery Bleed

Abstract Injury to the superior gluteal artery as a result of pelvic fracture is well recognized. Superior gluteal artery bleed leading to gluteal compartment syndrome without fracture of the pelvis has been reported but is extremely rare. Similarly, acute compartment syndrome of the thigh is rare. As far as is known, no previous case has been reported where a combination of pelvic fracture and superior gluteal artery bleed has led to acute gluteal and thigh compartment syndrome. We report on such a patient who developed these complications and highlight the importance of early detection, which may be difficult in an unconscious or comatose patient.     

Anterior thigh compartment syndrome after prone positioning for lumbosacral fixation

We report a case of a patient who developed anterior thigh compartment syndrome after being positioned prone for instrumented lumbar spine surgery. Although rare, clinicians should be aware that compartment syndrome is a possible complication of spinal surgery.     

Compartment syndrome after closure of the anterolateral thigh flap donor site: a report of two cases

Two male sarcoma patients developed a compartment syndrome in the thigh after the harvest and direct closure of the anterolateral thigh flap donor site. In each case, the absence of signs or symptoms led to a delay in diagnosis and treatment. Although use of the anterolateral thigh flap is increasingly popular for soft tissue reconstruction, this complication has not yet been reported. The cases and likely etiological factors are discussed as are recommendations for avoiding this devastating complication.     

Treatment of compartment syndrome of the thigh associated with acute renal failure after the Wenchuan earthquake

Compartment syndrome of the thigh is a rare emergency often treated operatively. The purpose of this study was to evaluate the effects of nonoperative treatment for compartment syndrome of the thigh associated with acute renal failure after the 2008 Wenchuan earthquake. Nonoperative treatment, which primarily involves continuous renal replacement therapy, was performed in 6 patients (3 men and 3 women) who presented with compartment syndrome of the thigh associated with acute renal failure. The mean mangled extremity severity score (MESS) and laboratory data regarding renal function were analyzed before and after treatment, and the clinical outcome was evaluated at 17-month follow-up. Laboratory data regarding renal function showed improvements. All 6 patients survived with the affected lower limbs intact after nonoperative treatment. Follow-up revealed active knee range of motion and increased muscle strength, as well as a recovery of sensation. A positive linear correlation was found between MESS and the time required to achieve a reduction in swelling, as well as the time required for the recovery of sensation and knee range of motion (r>0.8; P<.05). Satisfactory clinical outcomes were obtained in patients with compartment syndrome of the thigh associated with acute renal failure.Urine alkalization, electrolyte and water balance, and continuous renal replacement therapy have played an important role in saving lives and extremities. Nonoperative treatment should be considered in the treatment of compartment syndrome of the thigh associated with acute renal failure.     

Compartment syndrome of the thigh: A systematic review

Introduction

Thigh compartment syndrome is a surgical emergency with risk of high morbidity and mortality rates. The purpose of this study was to review the available evidence regarding the causes of thigh compartment syndrome, techniques of fasciotomy (specifically, one versus two incisions), methods of wound closure, and complications.

Methods

This institutional review board-exempt study was performed at a level-one trauma centre. PubMed and Medline OVID databases in the English language were searched for case series of two or more cases of compartment syndrome of the thigh. Cases were reviewed and analysed for causes of thigh compartment syndrome, number of fasciotomy incisions, methods of wound closure, and complications.

Results

A total of 9 papers met our criteria. All were retrospective case studies comprising a total of 89 patients. The most common cause was blunt trauma (90%). Motor vehicle accidents accounted for 36% of cases whilst motorcycle accidents were involved in 9%. Associated injuries included femur fractures in 48%, other limb fractures, renal, cardiovascular and head insults. Eighty-six percent of fasciotomies were performed through a single incision. Fifty-nine percent of fasciotomy wounds were closed by delayed primary closure, 26% had split-thickness skin grafts, and 15% had primary wound closure. Neurological deficits were the most common complications.

Conclusion

There are limited data on thigh compartment syndrome with respect to cause, use of one versus two incisions for fasciotomy, methods of wound closure, and complication rates. Prospective studies are required to better define these variables in order to optimise the management of this problem.     

Multiple compartment syndrome in a pediatric patient with CML

Compartment syndrome is a limb-threatening and life-threatening emergency resulting from elevated intracompartmental pressure. Prompt surgical intervention and treatment are necessary to prevent irreparable damage to muscle and nerve tissues. Leukemic infiltration of the muscle is an unusual cause of compartment syndrome and has been documented to occur secondary to hyperleukocytic leukemias, most commonly in acute myeloid leukemia. We present a rare case of multiple compartment syndrome in the buttock and thigh of an 11-year-old male patient with chronic myelomonocytic leukemia. The diagnosis of acute compartment syndrome was delayed, causing irreversible tissue damage. Physicians are generally unfamiliar with leukemia-induced complications and may not initially suspect leukemic compartment syndrome because of its rarity. Awareness of its clinical features is critical, because early diagnosis and prompt surgical debridement can prevent significant morbidity and even death.     

Acute compartment syndrome in the thigh. A case report and a review of the literature

Compartment syndrome in the thigh is an uncommon condition, and acute compartment syndrome without an associated fracture is even less common. An 18-year-old male developed an acute anterior compartment syndrome in the thigh from a contusion without an associated fracture. This syndrome was treated successfully with a fasciotomy.     

Conservative treatment of an acute compartment syndrome of the thigh

Compartment syndromes of the thigh after blunt trauma without any fracture are rare. Most surgeons recommend operative treatment. There are different rules for compartment syndromes of the thigh in young athletes after blunt trauma compared to compartment syndromes at other locations [(1) the large volume of the quadriceps muscle, (2) its relatively elastic fascia, (3) the direct proximal contact to the hip muscles which allows extravasation of fluid out of the compartment)]. We present a case of conservative treatment of elevated intra-compartmental pressure (ICP) of the anterior thigh after blunt trauma and the follow-up until return to sport. Conservative treatment of a compartment syndrome of the thigh after blunt trauma in a young patient without fracture or vascular damage was successful without short-term sequelae. Recovery of muscle strength is delayed but return to sport is possible. Depending on the severity the diagnosis and follow-up with ICP measurements and MRI is necessary. There is a very good chance for excellent outcome without any risk of surgery. However, a long healing time is possible.     

急性股部筋膜间室综合征的诊断与治疗

目的：分析讨论急性股部筋膜间室综合征的诊断与治疗。方法：经测压确诊8例股部筋膜间室综合征病例，行股部内、外侧切口进行股部外、内及后部筋膜间室切开减压。结果：2例术后第3d及第4d死亡，6例存活，患肢均遗有严重的感觉及运动障碍，丧失工作能力。结论：急性股部筋膜间室综合征是一严重创伤性疾病，病死及病残率高，愈后差。正确的股部切开减压及预防多脏器功能衰竭是抢救成功的关键。     

Surgical demographics of acute thigh compartment syndrome

BackgroundThe objective of this study was to identify demographic, injury-related, and treatment-related characteristics of patients who underwent decompressive fasciotomies for acute thigh compartment syndrome.MethodsA cohort of 38 adult patients with acute thigh compartment syndrome treated with fasciotomy at two tertiary care referral centers over a 10-year time period from January 1, 2006 to June 30, 2015 were retrospectively identified. We searched the electronic medical record for patient-related variables (e.g., age, sex, race, smoking status, diabetes mellitus), injury-related variables (e.g., mechanism of injury, associated fractures, other traumatic injuries), treatment-related variables (e.g., delay to treatment, compartments released, number of debridements, use of split-thickness grafts), and outcomes (e.g., amputation, death, sensory/motor impairments at final follow-up).ResultsThe mean age of our cohort was 47 years, and 35 patients (92%) were male. There were various mechanisms of injury, but the most common mechanisms were spontaneous hematoma (21%), followed by motor vehicle accidents (16%). Associated leg fractures were present in 15 (39%) patients. Delay between time of injury and fasciotomy was greater than 24 hours in 27 patients (71%), 12 to 24 hours in 6 patients (16%), and less than 6 hours in 3 patients (8%). The most frequently released compartment was the anterior compartment only (68%), followed by both the anterior and posterior compartments (16%) and the posterior compartment only (11%). Six patients (16%) had motor impairment, and 2 patients (5%) had sensory impairment at final follow-up. There were 2 deaths (5%) recorded in the hospital course for this cohort, none of which were directly related to compartment syndrome of the thigh.ConclusionDelays to fasciotomy are frequent in the treatment of acute thigh compartment syndrome. The demographics of acute thigh compartment syndrome demonstrate a strong male predominance. Treating providers should recognize spontaneous hematoma and motor vehicle accidents as the most common causes of acute thigh compartment syndrome.