Acute compartment syndrome of the thigh is a rare but potentially devastating condition that has been associated with multiple etiologies including motor vehicle trauma,30 femur fractures,4,34 vascular injury,2 contusion,19,26 the use of antishock trousers,14 external compression caused by narcotic overdose or intraoperative positioning,18,20 muscular exertion,5,11 coagulopathy and intramuscular hematoma,6,12 hip and knee arthroplasties,16,32 knee arthroscopy,7 and epidural analgesia.24 In addition to its variable etiology, acute thigh compartment syndrome has been associated with a variable clinical spectrum and outcome. Although some patients have high morbidity and mortality, others have an uncomplicated course with full functional recovery. The reasons for this are not understood completely, and there is limited existing literature available on this condition. Although this clinical entity is reported with increasing frequency, most information on the clinical spectrum of thigh compartment syndrome is limited to small series or individual case reports. The only large study available to date described 17 patients with trauma who had acute thigh compartment syndrome and had a high incidence of short-term and long-term complications with frequent sepsis and an associated mortality rate of 47%.30 In contrast, two reports have described isolated acute thigh compartment syndrome in athletes resulting in full functional recovery and a return to international-level competition.15,19 This substantial discrepancy between clinical presentation and outcome had led to conflicting recommendations for clinical treatment of acute thigh compartment syndrome ranging from emergent fasciotomy to nonoperative treatment.25,30 The limited experience with acute thigh compartment syndrome likely contributes to the current controversy. To investigate the factors responsible for the difference in clinical presentation and outcome we gathered, from three trauma centers, a large group of patients diagnosed with acute compartment syndrome of the thigh. Systematic review of the patients was done to provide a comprehensive overview of the clinical presentation of acute thigh compartment syndrome and to define the relevance of its clinical symptoms, laboratory parameters, surgical findings, and associated injuries for the development of short-term morbidity and mortality.
MATERIALS AND METHODS
A retrospective analysis of the hospital charts of three Level 1 trauma centers was done between January 1, 1990 and January 31, 2002. The study protocol for human subjects was approved by the Institutional Review Board at each participating institution. Twenty-eight patients with 29 compartment syndromes of the thigh were identified. Twenty-three patients were men and five patients were women with an average age of 39.9 years (range, 18–81 years). Data collected from chart review included mechanism of injury, associated injuries, presence of hypotension, compartment pressures, neuromuscular function, radiographic changes, intraoperative findings and procedures, length of hospitalization, and short-term complications. Recorded laboratory data included creatine-phosphokinase levels, urine myoglobulin, prothrombin time (PT), and partial thromboplastin time (PTT). Coagulopathy was defined as a PT-INR > 1.4 or PTT greater than 40 seconds at the time of presentation. Associated injuries were used to calculate individual Injury Severity Scores (ISS). The ISS stratifies injuries from minor to fatal on a six-point scale in nine defined body sections. The final score presents the sum of the squares of the highest injury grades in the three most severely injured body regions with a range from 1–75 points.1 Time from injury to surgical decompression was calculated from emergency room or paramedic reports and anesthesia records.
The diagnosis of acute thigh compartment syndrome in patients who were awake and able to cooperate with examination was based on the presence of the diagnostic criteria previously described for acute compartment syndrome.17,21,22 Diagnostic clinical symptoms included thigh pain out of proportion to the severity of injury, significant swelling, and palpable induration of the involved compartment, measured thigh circumference, pain with passive stretch, weakness of the involved thigh muscles, or sensory or motor deficits in the anatomic distribution of the nerves contained in the involved compartment. Each patient who was conscious had at least two of these clinical symptoms. Acute thigh compartment syndrome in awake patients was diagnosed based on these documented diagnostic clinical symptoms. Decreased or absent distal pulses in the involved extremity were recorded but not used as diagnostic signs for thigh compartment syndrome. Measurement of interstitial compartment pressures was done in all documented cases with a hand-held pressure-monitoring device (Stryker, Kalamazoo, MI). The time of the pressure measurement or the interval from injury to measurement of compartment pressures was not separately documented in any of the reviewed charts. No continuous monitoring was done. Pressure monitoring assumed only an adjunctive role in the diagnosis in awake patients. In contrast, pressure monitoring was critical in the diagnosis of acute thigh compartment syndrome in patients who were unable to cooperate with physical examination. Interstitial compartment pressures of 30 mm Hg or greater have been described as critical for the development of myoneural necrosis36 and were chosen as the diagnostic threshold in all patients suspected of having acute thigh compartment syndrome. In addition, the difference between systemic blood pressure and intracompartmental pressure (ΔP) was determined. Fasciotomy in all cases was done according to the principles described by Tarlow et al.34 Briefly, a lateral incision was used to expose the fascia lata, which was incised to access the anterior compartment. The vastus lateralis was retracted medially to expose the lateral intermuscular septum, which was incised for decompression of the posterior compartment. If needed, access to the medial compartment was gained by incision of the posterior intermuscular septum through the posterior compartment. Statistical analysis was done using standardized parametric and nonparametric tests. Values are expressed as mean ± SEM. A p value < 0.05 was considered significant.
Of the 28 patients who met the study criteria, acute compartment syndrome of the thigh resulted from motor vehicle accidents in 13 patients (46%), and contusion in 11 patients (39%). Contusion resulted from blunt impact after falls in six patients and sports-related player contact in five patients. Chronic compression after opiate overdose, vascular injury after gunshot injury, exertional compartment syndrome, and complication of femoral bypass each were present in one patient (4%). None of the patients had been treated with military antishock trousers (MAST). Twenty-seven patients (96%) had unilateral involvement of the thigh and one patient (4%) had bilateral thigh compartment syndromes. Injury Severity Scores for the entire patient group averaged 11.9 ± 2.4 points. Four patients had multiple injuries involving more than three organ systems with an associated ISS of 36.2 ± 4.8 points. An ipsilateral femur fracture was present in 15 of 29 compartment syndromes (52%). Femur fractures resulted from motor vehicle accidents in 11 patients and falls in two patients. The average ISS was 17.8 ± 3.5 points in patients with ipsilateral femur fracture compared with 5.0 ± 2.4 points in patients without associated fracture (p = 0.006). The ISS in patients involved in a motor vehicle accident were higher than in patients with thigh compartment syndrome not related to a motor vehicle accident (19.3 ± 3.6 points and 5.4 ± 1.8 points, respectively, p = 0.003). Five patients (18%) were hypotensive at the time of presentation including all patients with an ISS greater than 27.
Clinical symptoms of acute thigh compartment syndrome were comparable to those in other anatomic regions. A tensely swollen thigh was present in all 28 patients. Nine patients were unconscious at the time of examination. Thigh circumference was documented in six of the nine patients unable to cooperate and showed an increase of 4.8 ± 0.7 cm (range, 2–7 cm) compared with the contralateral side. Intolerable pain was present in all 20 involved thighs of the 19 awake patients. Passive stretch testing of the thigh muscles was documented in 15 awake patients and was associated with significant pain in all cases. Focal paresthesias were recorded in 12 of 20 thighs in awake patients (60%) and involved the saphenous nerve distribution in six patients, anterior cutaneous distribution of the thigh in two patients, peroneal distribution in three patients, and medial plantar distribution in one patient. Paralysis was documented in eight of 20 involved extremities (42%) and involved the quadriceps muscle in seven extremities and extensor hallucis longus in two extremities with an average grading of 2/5 (range, 0–3/5). Absent pulses by palpation and Doppler ultrasound were seen in six of 29 thighs (21%) (Table 1). Involved compartments were anterior (100%), posterior (10 patients, 34%), and adductor (five patients, 17%).34 Compartment pressures were reported in 22 of 29 thighs (76%) and averaged 58 ± 3.4 mm Hg, 59 ± 10.2 mm Hg, and 52 ± 9.6 mm Hg in the anterior, posterior, and adductor compartments, respectively. The difference of intracompartmental and blood pressure (ΔP) averaged 39 ± 4 mm Hg and was 16 ± 3 mm Hg in patients with polytrauma with an ISS greater than 27. The presence of an ipsilateral femur fracture did not significantly influence the compartment pressure. No statistical association between compartment pressures and incidence of myonecrosis (r = 0.136), need for additional surgery (r = 0.144), skin grafting (r = 0.097), or the time to decompression (r = 0.219) could be established.
Laboratory analysis confirmed the clinical importance of monitoring laboratory parameters in patients with acute compartment syndrome of the thigh and showed their relevance for development of short-term morbidity and mortality associated with this clinical entity. Mean serum creatine-phosphokinase (CPK) levels averaged 22,076 ± 7524 mU/mL (range, 297–116,600 mU/mL) and were most elevated after motor vehicle accidents (25,159 ± 10,400 mU/mL) and blunt trauma with associated femur fracture (28,996 ± 12,411 mU/mL). Serum levels were significantly lower after contusion (2344 ± 966 mU/mL; p = 0.032) and blunt trauma without associated femur fracture (571 ± 113 mU/mL; p = 0.02). After decompression CPK concentration increased transiently in ⅔ of the patients to 23,966 ± 8922 mU/mL. Creatine-phosphokinase levels did not correlate with ISS (r = 0.256), compartment pressures (r = 0.02), or time after injury (r = 0.22). There was no difference between patients with (22,009 ± 17,608 mU/mL) or without dysvascular extremities (22,090 ± 8537 mU/mL; p = 0.997). Myoglobulinuria was detected in five patients (18%) and was associated with high CPK levels (66,202 ± 13,898 mU/mL). Three of these five patients had acute tubular necrosis develop for which they required hemofiltration, and two of these three patients had multiorgan system failure and death. Abnormal coagulation parameters were present at the time of initial presentation in 11 patients (39%) and because of use of anticoagulants in four patients (14%), disseminated intravascular coagulation (DIC) in four patients (14%), and von Willebrand’s disease in one patient (4%). Two patients (8%) responded to medical correction of coagulopathy and showed no abnormality of the coagulation cascade on subsequent hematologic evaluation. Ten of the 11 patients with coagulopathy had massive hematoma formation in the involved thigh compartments. Angiography showed lacerations involving the profunda femoris artery in two patients, the superficial femoral artery in one patient, and external iliac artery in one patient. All femoral artery injuries were associated with ipsilateral femur fractures (Fig 1). Successful embolization was done in three patients, with primary surgical repair in the remaining patient.
Surgical data showed the benefit of early surgical decompression in limiting acute complications from acute thigh compartment syndrome. The mean interval to surgical decompression was longer for patients without femur fractures (Table 2). Fasciotomy was done in 25 of 29 thigh compartment syndromes (86%) at a mean of 11.1 ± 3.0 hours (range, 2–72 hours) after injury. Cardiopulmonary instability prevented operative intervention in two patients who later died. Two patients with isolated thigh contusions had dramatic clinical improvement and decreased pain with passive stretch, resolution of hypoesthesias, and/or decrease of compartment pressures to normal values after 4–6 hours of preoperative rest, cryotherapy, and fluid administration. Ipsilateral femur fracture was treated with simultaneous intramedullary stabilization in 11 patients and dynamic compression plating in two patients. One patient treated with skeletal traction died before definitive fracture fixation. Time to decompression was independent of ISS (r = 0.273) but correlated with the incidence of short-term complications from acute thigh compartment syndrome (r = 0.691; p < 0.001). At fasciotomy, immediate extrusion of the muscle through the incised fascia was seen in all patients, confirming the diagnosis. Significantly edematous but contractile muscle was present in 16 patients (64%), myonecrosis in eight patients (32%), and muscle laceration in five patients (20%) having operative treatment (Table 2). Seventy-five percent of patients with myonecrosis had associated ipsilateral femur fractures. Evacuation of 0.5–2.5 L of hematoma was done in 19 patients (76%) (Fig 2). An average of 2.0 ± 0.4 additional procedures were required until wound closure. In 15 patients (62%), delayed primary closures were achieved at the primary return to the operating room. Three patients (12%) required skin grafting, all of whom had ipsilateral femur fractures.
In addition to its correlation with the time to fasciotomy, the incidence of short-term complications was higher in patients with ipsilateral femur fractures (57%) than in patients with isolated thigh compartment syndromes (7%, p = 0.041). Septic complications were observed in five patients (18%) and included systemic sepsis in three patients and local wound sepsis in two patients. Eighty percent of septic complications were associated with femur fractures. All patients with systemic sepsis died whereas both patients with wound infection had delayed primary closures. Four of the patients with septic complications had multiple injuries with an average ISS of 32 ± 7 (range, 17–50). Overall mortality was three of 28 patients (11%). Mortality was 75% and significantly higher in multiply-injured patients with ISS greater than 27 points than in patients with ISS less than 27 points (0%, p < 0.0001) (Fig 3). The severity of the injuries also was reflected in the length of hospitalization which correlated with ISS (r = 0.577, p < 0.001). Hospitalization averaged 16.7 ± 2.1 days (range, 2–43 days) and was significantly longer after blunt thigh trauma with ipsilateral femur fracture (20.6 ± 3.0 days) than without femur fracture (10.6 ± 2.9 days, p = 0.027). Patients involved in a motor vehicle accident (22.2 ± 3.5 days) had significantly longer hospital stays than patients with isolated contusions (6.4 ± 1.7 days, p = 0.004).
The limited clinical experience with acute compartment syndrome of the thigh and its variable clinical presentation has prevented a clear understanding of this condition and its clinical treatment is controversial. We aimed to improve the current understanding of the reasons for this variability by retrospectively reviewing a sizable group of patients diagnosed with acute thigh compartment syndrome. We recognize the limitations of the retrospective study design such as incomplete documentation of diagnostic and therapeutic steps and decision-making process, however, because of the rarity of acute thigh compartment syndrome, prospective studies on this condition are difficult to accomplish. The current study presents a first step to expand the currently limited knowledge of this potentially devastating clinical entity by studying the largest patient series reported to date with acute thigh compartment syndrome.
Blunt trauma from motor vehicle accidents or direct thigh contact were the most frequent causes of thigh compartment syndrome in the patients in our study. Similarly, Schwartz et al30 described blunt trauma as the cause of thigh compartment syndrome in 76% of their patients. Fifty-eight percent of their patients presented with ipsilateral femur fractures, which was similar to the 52% incidence observed in our study population. Contusion was the second most common cause of acute thigh compartment syndrome in our patients and has been reported more frequently among athletes.15,19,25,26
In our cohort, the most consistent indicator of acute thigh compartment syndrome in awake patients was an excessively painful, tensely swollen thigh, which has been reported consistently.2,6,7,12,14,16,18,24,25,26,32 Simple measurement of the thigh circumference was helpful to determine progression or improvement of the swelling. Pain with passive stretch has been described as a highly sensitive indicator of compartment syndrome in the lower leg but no prior information is available for the thigh. Pain with passive stretch may result from ischemia-induced loss of intramuscular high-energy phosphates affecting cross bridging of myofilaments with associated resistance to passive stretch and resultant pain.29 Changes in intramuscular pressure caused by decreased compartment volume from stretching is another possible explanation.9 Although this symptom had a sensitivity of 100% in our study, it cannot be considered specific because ipsilateral femur fracture or stretching of contused muscle also will cause pain. Paresthesias are an important diagnostic sign and important indicator for fasciotomy.21 Paresthesias in the distribution of the involved compartment were observed in 60% of our patients and have been described in 12% of patients with isolated contusions26 and in 100% of severely injured patients with trauma who have acute thigh compartment syndrome.30 Similarly, paralysis was observed in 42% of our mixed patient population compared with an 80% incidence found in the trauma population.30 These findings support the previously described effect of associated soft tissue injury on the symptoms from acute thigh compartment syndrome.4,28,34 Absent pulses were seen in only 21% of our patients and were associated with angiographically documented vascular injury in ⅔ of these patients. Most vascular injuries (75%) were associated with ipsilateral femur fractures, which was consistent with the 66% incidence of vascular injuries associated with femur fractures observed by other investigators.34 Although the pulse status has limited diagnostic value in compartment syndrome,17 absent pulses should raise suspicion for a vascular laceration, particularly if an ipsilateral femur fracture is present.34 Eighteen percent of patients with thigh compartment syndrome were hypotensive and typically had increased ISS. A previous study suggested that systemic hypotension at the time of admission is a risk factor for development of thigh compartment syndrome.30 From our data, it was not possible to identify hypotension as a risk factor. Because hypotension lowers ΔP and aggravates ischemia-induced muscular injury in compartment syndrome,36 it should be corrected.
In addition to clinical symptoms, the relevance of laboratory parameters associated with acute thigh compartment syndrome was analyzed. Previous studies have shown that elevation of serum CPK in isolated compartment syndrome reflects the amount of muscular damage.20,21 Our data suggest a similar association for thigh compartment syndrome, because moderate CPK elevations were observed in patients with isolated thigh compartment syndrome resulting from contusion, whereas significantly higher CPK levels were present in patients with thigh compartment syndrome after high-energy motor vehicle accidents, or patients with associated femur fractures. Muscular injury in other body regions in multiply-injured patients may have contributed to the higher CPK increase in that population. However, in our study, we were unable to show a correlation between CPK levels and ISS. Our data suggest that excessive elevations of serum CPK may lead to prolonged hospitalization and high mortality rate. This may be related to the development of myoglobulin-induced acute renal failure, which was present in 60% of patients with levels in excess of 65,000 mU/mL in our study. The previously described mortality rate of 86% in patients with thigh compartment syndrome associated with myoglobinuria and acute renal failure additionally supports this conclusion.30 Close monitoring of CPK levels and urine output, aggressive intravenous fluid therapy, and alkalinization of the urine will help to prevent acute renal complications.5,33 Coagulopathy has been described as a risk factor for the development of thigh compartment syndrome and was present in 39% of our patients.23,30 Similar to several previous studies, 91% of patients with coagulopathy in our study had large hematoma formation.6,12,19 This suggests a high index of suspicion for an impending thigh compartment syndrome if coagulopathy is detected in a patient with a tense, swollen thigh.
Compartment pressures were the primary diagnostic test in patients unable to cooperate with an examination, but were given less importance when clear clinical symptoms were present.17,30 Zweifach et al36 reported that intracompartmental pressures of 30 mm Hg or greater even under normotensive conditions produced major myonecrosis and suggested this threshold as a clinical indicator for fasciotomy. Other authors have suggested a critical value of 45 mm Hg17 or ΔP of compartment pressure and mean diastolic pressure of less than 30 mm Hg.35 However, most values are derived from other anatomic sites and the pressure threshold for the thigh musculature has not been defined separately. Although compartment pressures were elevated in all patients, we were unable to identify a critical pressure threshold for the thigh. This may have resulted from the variable individual tolerance to elevated thigh compartment pressures17,35 or the variability of isolated pressure measurements or the retrospective nature of our study. Prospective studies with larger patient numbers are needed, but may be difficult to accomplish because of the rarity of this syndrome.
Besides the magnitude of the compartment pressures, the duration of the pressure elevation is equally important.31 The average time from injury to decompression of 11 hours in patients in our study was longer than in previously reported clinical and experimental studies.10,30 The extended interval to decompression observed in our patients could be secondary to delayed diagnosis or the presence of other injuries, which precluded immediate fasciotomy. The longer interval to fasciotomy with isolated thigh compartment syndrome may have resulted from a more gradual development of symptoms and later clinical presentation of these patients compared with patients with immediate symptoms from femur fractures. Our results emphasize the need for a high index of suspicion for isolated thigh compartment syndrome. Delayed fasciotomy was associated with increased complications, which is consistent with results of previous studies that showed a correlation between the timing of fasciotomy and incidence of complications.17,31 The low incidence of complications in patients with isolated thigh compartment syndrome suggests that the thigh musculature may be able to tolerate elevated compartment pressures for longer periods than other regions. This previously has been suggested and was attributable to the large volume of the compartments in the thigh and relative elasticity of its fasciae.25,30,34 However, our results indicate that this thigh muscle tolerance may be limited, particularly if additional thigh trauma such as fracture or nerve injury is present, which is supported by previous clinical and experimental observations.3,28 Therefore, emergent fasciotomy is the gold standard for treatment if symptoms of acute compartment syndrome are present.22,30,31 At fasciotomy, large hematoma formation was observed in 76% of patients and treated with evacuation. Hematoma evacuation avoids continued hemorrhage caused by the fibrinolytic activity in the hematoma13 and can help to reduce complications such as heterotopic ossification27 or delayed compartment syndrome.19 Bleeding from vascular injury is seen more often in patients with high-energy trauma, whereas intramuscular hematoma formation often results from lower-energy trauma associated with contact sports.19,25,26 The former may lead to rapid accumulation of hematoma, and the latter may cause a more gradual increase in compartment pressure. Rapid hematoma formation may limit the ability of the thigh to compensate and increase the risk for development of acute compartment syndrome and myonecrosis.
Wound complications were seen in only 18% of our patients and mostly were limited to patients with multiple injuries. Wound infection after thigh fasciotomy has been described in as many as 67% of patients with need for skin grafting in 78%.30 This high complication rate has led some surgeons to hesitate with surgical decompression34 or even propose nonsurgical treatment.25 The compromised immune response and poor granulation may account for the high incidence of septic wound complications observed in the polytrauma population with thigh compartment syndrome.30 Because of the low morbidity associated with fasciotomy in our study, avoiding fasciotomy to prevent complications seems unwarranted. Delayed surgical decompression may increase the incidence of septic wound complications.31 The use of broad-spectrum antibiotic prophylaxis and vacuum-assisted wound care techniques also may help to reduce the incidence of septic complications from fasciotomy.8 Complications were rare in patients with isolated thigh compartment syndrome but developed in 57% of patients with additional bony or vascular injuries to the involved thigh. This finding is supported by experimental studies that showed that associated injuries of bone, vessels, or nerves are related directly to the severity of the changes in the traumatized soft tissue.3,28 This also is consistent with the higher incidence of myonecrosis associated with ipsilateral femur fracture in patients in our study. The influence of associated injuries also is reflected in the mortality rate in our patients. Overall mortality in our mixed patient population only was 11%, which is significantly lower than the 47% mortality rate reported in association with thigh compartment syndrome in patients with trauma.30 Our observation that death occurred only in patients with ISS greater than 27 points supports the conclusion that mortality in these patients results from multiple injuries and not as a result of the thigh compartment syndrome.
Acute thigh compartment syndrome is characterized by a variable etiology and presents with features typical for compartment syndrome. Tense swelling, pain with passive stretch, and paresthesias in the distribution of the involved compartment are the most reliable symptoms. Assessment of compartment pressures assumes significant diagnostic relevance in unconscious patients but is of less diagnostic value when assessing alert, cooperative patients. The critical compartment pressure threshold in the thigh has yet to be defined. Fasciotomy provides effective treatment with minimal morbidity. The incidence of short-term complications is related to associated injuries whereas mortality is limited to patients with polytrauma.
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