Updated: 11/13/2018

Thigh Compartment Syndrome

Topic
Review Topic
0
0
Videos
1
https://upload.orthobullets.com/topic/1063/images/thigh compartment syndrome.jpg
https://upload.orthobullets.com/topic/1063/images/thigh compartments master.jpg
https://upload.orthobullets.com/topic/1063/images/thigh compartment release.jpg
Introduction
  •  Devastating condition where an osseofascial 
    compartment pressure rises to a level that decreases perfusion
  • May lead to irreversible muscle and nerve damage
  • May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
    • leg
    • forearm
    • hand
    • foot
    • thigh (details below)
    • buttock
    • shoulder
    • paraspinous muscles
  • 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
Evaluation 
  • Diagnosis
    • based primarily on physical exam in patient with intact mental status
  • Radiographs
    • obtain to rule-out fracture
  • 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
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 with absolute value of 30-45 mm Hg
        • 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
Surgical 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
 
 

Please rate topic.

Average 4.1 of 32 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
VIDEOS (1)
Topic COMMENTS (0)
Private Note