Updated: 5/23/2021

Thigh Compartment Syndrome

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  • Introduction
    • Devastating condition where an osseofascial compartment pressure rises to a level that decreases perfusion
      • May lead to irreversible muscle and nerve damage
  • 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
Evidence (2)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (2)
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