Acute morbidity and complications of thigh compartment syndrome: A report of 26 cases

Abstract

Background: To describe the patient population, etiology, and complications associated with thigh compartment syndrome (TCS). TCS is a rare condition, affecting less than 0.3% of trauma patients, caused by elevated pressure within a constrained fascial space which can result in tissue necrosis, fibrosis, and physical impairment in addition to other complications. Compartment releases performed after irreversible tissue ischemia has developed can lead to severe infection, amputation, and systemic complications including renal insufficiency and death.

Methods: This study examines the course of treatment of 23 consecutive patients with 26 thigh compartment syndromes sustained during an eight-year period at two Level 1 trauma centers, each admitting more than 2,000 trauma patients yearly.

Results: Patients developing TCS were young (average 35.4 years) and likely to have a vascular injury on presentation (57.7%). A tense and edematous thigh was the most consistent clinical exam finding leading to compartment release (69.5%). Average time from admission to the operating room was 18 +/- 4.3 hours and 8/23 (34.8%) were noted to have ischemic muscle changes at the time of release. Half of those patients (4/8) developed local complications requiring limb amputations.

Conclusion: TCS is often associated with high energy trauma and is difficult to diagnose in uncooperative, obtunded and multiply injured patients. Vascular injuries are a common underlying cause and require prompt recognition and a multidisciplinary approach including the trauma and orthopaedic surgeons, intensive care team, vascular surgery and interventional radiology. Prompt recognition and treatment of TCS are paramount to avoid the catastrophic acute and long term morbidities.

Figure 1

Angiogram of thigh vessels in young female patient on bicycle who was hit by car one hour before admission. She was in hemorrhagic shock, with peripheral pulses and sensation present, with unstable femoral shaft fracture and with clinical presentation of thigh compartment syndrome. Arterial bleed was diagnosed by angiography and damaged arterial brunch was promptly embolized. All three thigh compartments were released, femur fracture was fixed with intramedullary nail and patient had good final outcome.

Figure 2

Antero-posterior x-ray of unstable pertrochanteric fracture sustained after simple fall by an elderly patient. Eighteen hours after the injury he started developing signs of acute thigh compartment syndrome and was taken urgently to operating room for anterior thigh compartment fasciotomy. Muscles were still valuable and fracture fixation with cephalomedullary nail was done immediately after. Patient did not have any history of hemorrhagic diathesis, was not taking any blood thinners and there were no abnormalities on patient routine preoperative workup (PT, PTT, INR, platelets). He recuperated well.

Figure 3

Clinical photo of male patient in his forties who was hit by car day before. He presented with significant swelling of his left thigh and gradually increasing pain especially on attempts of knee flexion. Anterior thigh compartment was very tense, measured pressure was close to diastolic pressure; distal pulses and sensation were intact.

Figure 4

Antero-posterior femur x-ray has not revealed any fracture.

Figure 5

Small incision thorough the fascia allowed for inspection of quadriceps muscles viability. Muscle was alive reacting promptly with contractions on pinch with forceps and electro-cautery touch.

Figure 6

Partial fasciotomy with muscle still under pressure.

Figure 7

Complete antero-lateral fasciotomy was done with muscle escaping high intra-compartmental pressure.

Figure 8

Clinical photo of well functioning patient few weeks after the injury. The soft tissue defect was treated with negative pressure wound therapy immediately after fasciotomy followed by successful split thickness skin grafting six days after.