SUMMARY

• Thigh Compartment Syndrome is a devastating lower extremity condition where the osseofascial compartment pressure rises to a level that decreases perfusion to the thigh and may lead to irreversible muscle and neurovascular damage.

• Diagnosis is made with the presence of severe and progressive thigh pain that worsens with passive knee motion. Firmness and decreased compressibility of the compartments is often present. Needle compartment pressures are diagnostic in cases of inconclusive physical exam findings and in sedated patients.

• Treatment is usually emergent fasciotomies of all 3 compartments. 

EPIDEMIOLOGY

• Anatomic location

  • May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly

    • leg 

    • forearm 

    • hand 

    • foot 

    • thigh (details below)

    • buttock

    • shoulder

    • paraspinous muscles

ETIOLOGY

• Pathophysiology

  • local trauma and soft tissue destruction >

  • bleeding and edema >

  • increased interstitial pressure >

  • vascular occlusion >

  • myoneural ischemia

• Causes

  • trauma (most common)

    • ipsilateral femur fractures

      • increased incidence with open fractures

    • crush injuries

    • contusions

    • gunshot wounds

  • tight casts, dressings, or external wrappings

  • extravasation of IV infusion

  • burns

  • postischemic swelling

  • bleeding disorders

  • arterial injury

ANATOMY

• 3 thigh compartments 

  • anterior compartment

    • muscles

      • quadriceps 

      • sartorious 

    • nerves

      • femoral nerve

  • posterior compartment

    • muscles

      • hamstrings 

    • nerves

      • sciatic nerve

  • adductor compartment

    • muscles

      • adductors 

    • nerves

      • obturator nerve

PRESENTATION

• Symptoms

  • pain out of proportion to clinical situation is usually first symptom

    • may be absent in cases of nerve damage

    • pain is difficult to assess in a polytrauma patient and impossible to assess in a sedated patient

    • difficult to assess in children (unable to verbalize)

• Physical exam

  • pain w/ passive stretch

    • is most sensitive finding prior to onset of ischemia

      • must test each compartment separately

        • anterior compartment

          • pain with passive flexion of knee

        • posterior compartment

          • pain with passive extension of knee

        • medial compartment

          • pain with passive abduction of hip

  • paraesthesia and hypoesthesia

    • indicative of nerve ischemia in affected compartment

  • paralysis

    • late finding

    • full recovery is rare in this case

  • palpable swelling

  • peripheral pulses absent

    • late finding

    • amputation usually inevitable in this case

IMAGING

• Radiographs

  • obtain to rule-out fracture

STUDIES

• Compartment pressure measurements

  • indications

    • polytrauma patients

    • patient not alert/unreliable

    • inconclusive physical exam findings

  • relative contraindication

    • unequivocally positive clinical findings should prompt emergent operative intervention without need for compartment measurements

  • technique

    • should be performed within 5cm of fracture site or area of maximal swelling

    • must test each compartment separately

DIAGNOSIS

• Clinical

  • based primarily on physical exam in patient with intact mental status

TREATMENT

• Nonoperative

  • observation

    • indications

      • delta p > 30, and

      • presentation not consistent with compartment syndrome

• Operative

  • emergent fasciotomy of all affected compartments

    • indications

      • clinical presentation consistent with compartment syndrome

      • compartment pressures within 30 mm Hg of diastolic blood pressure (delta p)

        • intraoperatively, diastolic blood pressure may be decreased from anesthesia

          • must compare intra-operative measurement to pre-operative diastolic pressure

    • contraindications

      • missed compartment syndrome

TECHNIQUES

• Thigh fasciotomies 

  • approach

    • anterolateral incision over length of thigh

  • technique

    • single incision technique for anterior and posterior compartments

    • incise fascia lata

    • expose and decompress anterior compartment

    • retract vastus lateralis medially to expose lateral intermuscular septum

    • incise lateral intermuscular septum to decompress posterior compartment

    • may add medial incision for decompression of adductor compartment

COMPLICATIONS

• Associated with significant long-term morbidity

  • over 50% will experience functional deficits including

    • pain

    • decreased knee flexion

    • myositis ossificans

    • sensory deficits

    • decreased strength