Under Pressure: An Uncommon Location for Compartment Syndrome
CASE
A 35-year-old-patient presents following motor vehicle collision as a restrained passenger. The vehicle's dashboard was displaced into the cabin, causing prolonged entrapment of the patient’s lower extremities. The patient’s left thigh was noted by EMS to have an obvious deformity with bleeding from an anterior wound. A tourniquet was placed to the proximal left thigh. A deformity was also noted to the right thigh without obvious external hemorrhage.
Upon arrival to the ED, primary survey was notable for Glasglow Coma Scale of 14 for confusion. The tourniquet was removed without significant bleeding. Total tourniquet time was approximately 1 hour and 45 minutes. Secondary exam was notable for bilateral thigh deformities. The anterior left thigh had a 3 cm laceration. The left lateral thigh compartment was tense and non-compressible.
Image 1: Anterior left thigh with deep laceration.
DIAGNOSIS
The patient was diagnosed with a left open femur fracture and right closed femur fracture. Lower extremity traction pins were placed bilaterally. Several hours after pin insertion, the patient developed a left foot drop. The Stryker intra-compartmental pressure monitor system was used to measure thigh compartment pressures, which were elevated and consistent with acute left thigh compartment syndrome. The patient was taken emergently to the operating room for left thigh fasciotomies.
Image 2: Left thigh angiogram showing displaced midshaft left femur fracture with contrast leakage lateral to the fracture site.
Image 3: Left thigh CT angiogram showing potential arterial extravasation fracture.
DISCUSSION
Acute thigh compartment syndrome (ATCS) is most commonly caused by blunt trauma and refers to the build up of pressure within the fascial compartments of the thigh, causing decreased perfusion, ischemia, and cell death.[1] Fewer than half of ATCS cases are associated with a femoral fracture.[1,2] ATCS can also develop due to an expanding hematoma secondary to vascular injury.[2,3] The three compartments in the thigh (posterior, lateral, and medial) each have distinct neurovascular and muscular structures that can be impinged upon by elevated compartment pressure.[4] Lower leg (calf) compartment syndrome is more common than that of the thigh.[1]
![Image 4: The compartments of the thigh and their associated structures.[4]](https://images.squarespace-cdn.com/content/v1/56e8a86a746fb97ea9d14740/1634054355878-IKN9DOU8LTJJ3VQ8BUH3/compartments.png)
Image 4: The compartments of the thigh and their associated structures.[4]
Early compartment syndrome usually presents as pain; patients may develop pallor, paresthesia, poikilothermy, and pulselessness. Collectively, these are known as the Five Ps.[2] The progression of symptoms can occur over the course of several hours to days, with arterial injury leading to more rapid development of elevated compartment pressures.[3] Complications of ATCS can be severe and are worsened by delays in treatment.[4] Especially in the absence of concurrent femoral fracture, clinicians may not suspect or recognize ATCS, even with an appropriate mechanism of injury.[2,5] Delay in surgical treatment can result in necrosis of the thigh muscle tissue. Sepsis is seen more frequently in patients with ATCS associated with femur fractures. Patients may also develop infections of their fasciotomy incisions, which may require skin grafting.[4] Prolonged elevation in compartment pressures may also cause chronic neurovascular deficits, such as motor weakness or numbness.[6] Mortality associated with ATCS has been described in several studies to be between 11% and 47%.[5,7]
Diagnosis of ATCS can be made clinically or with the use of pressure measurement devices.[1] Severe pain may be the first presenting symptom and is classically worsened by passive stretching of the thigh muscles.[2,5] Presence of the remaining Five Ps should increase suspicion for ATCS, but not all five are necessary to make the diagnosis. Patients will often have a swollen and tense thigh where the soft tissue is non-compressible, although this is not always appreciated.[5] Compartment syndrome can still occur in patients that present with open fractures. Patients with elevated creatinine kinase (CK) levels (>1000 U/mL) or diagnosis of rhabdomyolysis increases the likelihood of ATCS.[6] While imaging is not necessarily helpful in the diagnosis of compartment syndrome, patients with hemodynamic instability and symptoms of compartment syndrome should undergo arteriography of the affected limb to rule out vascular injury.[3]
The diagnosis is confirmed by measuring thigh compartment pressures using an intra-compartmental pressure monitoring system, such as the Stryker. To measure compartment pressures with this device, the Stryker is held perpendicular to the floor and a needle connected to the device is inserted into the compartment. A small amount of saline from an attached syringe is injected into the compartment to record the pressure. The compartment pressure is compared to the patient’s diastolic blood pressure, and if the ∆Pressure is ≤30 mmHg, compartment syndrome is confirmed.[6]
Video 1: Measuring Compartment Pressure - A demonstration on the use of the Stryker intracompartmental pressure monitor device.[8]
Patients with clinical signs of compartment syndrome or ∆Pressure ≤30 mmHg should undergo definitive treatment with fasciotomies.[6,9] Fasciotomy incisions open the extremity compartments, thus reducing pressure by increasing compartment volume. This will improve perfusion to affected tissues and prevent further ischemia.[9]
CASE RESOLUTION
After initial emergent fasciotomies, the patient was admitted to the Trauma Intensive Care Unit, where he was hemodynamically unstable. He returned to the operating room the same day for further irrigation and debridement of the left thigh with new fasciotomies performed on the left lower leg. He was able to wean off of vasopressors and was extubated. The patient returned to the operating room twice more for bilateral femur fixtures and fasciotomy closures. He was discharged to an acute rehab.
TAKE-AWAYS
ATCS is rare compared to lower leg compartment syndrome and usually presents after blunt trauma, such as in an MVC.
Complications of ATCS can include tissue necrosis, sepsis, chronic neurovascular deficits, and death.
Diagnosis should be made based on clinical suspicion or compartment pressure measurements.
The Five Ps include: pain, pallor, paresthesia, poikilothermy, and pulselessness. Patients may have one or more of these, but rarely present with all five.
Patients with ATCS usually have tense, non-compressible thigh compartments.
The Stryker intra-compartmental pressure monitoring system is used to measure compartment pressures.
∆Pressure (diastolic blood pressure – compartment pressure) ≤30 mmHg should make the diagnosis.
Patients should be evaluated by a trauma surgeon for prompt fasciotomies to the affected limb.
AUTHOR: Jeff Savarino, MD is a first year emergency medicine resident at Brown University/Rhode Island Hospital.
FACULTY REVIEWER: Rory Merritt, MD, MEHP is an attending physician and assistant professor of emergency medicine.
Keywords: compartment syndrome, Stryker, thigh, fasciotomy
Disclaimer: The patient provided consent for the use of case details and images in this blog post.
REFERENCES
[1] Ojike N, Roberts C, Giannoudis P. Compartment syndrome of the thigh: A systematic review. Injury. 2010;41(2):133-136.
[2] Nooh A, Wang C, AlAseem A, Harvey E, Bernstein M. Acute Thigh Compartment Syndrome due to an Occult Arterial Injury Following a Blunt Trauma. JBJS Case Connect.2020;10(1):e0506.
[3] Suzuki T, Moirmura N, Kawai K, Sugiyama M. Arterial injury associated with acute compartment syndrome of the thigh following blunt trauma. Injury. 2005;36(1):151-159.
[4] Karadsheh M. (2021, May 23). Thigh Compartment Syndrome. Retrieved from https://www.mendeley.com/guides/web-citation-guide.
[5] Mithöfer K, Lhowe D, Vrahas M, Altman D, Altman G. Clinical Spectrum of Acute Compartment Syndrome of the Thigh and its Relation to Associated Injuries. Clin Orthop Relat Res. 2004;425:223-229.
[6] Long B, Koyfman A, Gottlieb M. Evaluation and Management of Acute Compartment Syndrome in the Emergency Department. J Emerg Med. 2019;56(4):386-397.
[7] Schwartz J, Brumback R, Lakatos R, Poka A, Bathon G, Burgess A. Acute compartment syndrome of the thigh: A spectrum of injury. J Bone Joint Surg Am. 1989;71(3):392-400.
[8] Mason J, Hamud W. (2017, May 11). Measuring Compartment Pressure [Video]. YouTube. https://www.youtube.com/watch?v=XXp0EtKtlF8.
[9] Schmidt A. Acute compartment syndrome. Injury. 2017;48(1):S22-S25.