E-submission
KFS
Articles
- Page Path
- HOME > J Musculoskelet Trauma > Volume 37(4); 2024 > Article
-
Original Article
- Acute Compartment Syndrome of Thigh: Ten-Year Experiences from a Level I Trauma Center
-
Hyung Keun Song, M.D., Ph.D.
, Won-Tae Cho, M.D., Ph.D., Wan-Sun Choi, M.D., , Seung-Yeob Sakong, M.D., Sumin Im, M.D. -
Journal of Musculoskeletal Trauma 2024;37(4):171-174.
DOI: https://doi.org/10.12671/jmt.2024.37.4.171
Published online: October 25, 2024
Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Korea
- Correspondence to: Hyung Keun Song, M.D., Ph.D. Department of Orthopedic Surgery, Ajou University School of Medicine, 164 WorldCup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +8 2-31-219-5220 Fax: +8 2-31-219-5229 E-mail: ostrauma@ajou.ac.kr
• Received: July 16, 2024 • Revised: July 23, 2024 • Accepted: July 23, 2024
© 2024 The Korean Fracture Society
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- 176 Views
- 27 Download
Abstract
-
Purpose To assess the demographics, injury mechanisms, treatments, and outcomes of traumatic acute compartment syndrome in the thigh.
-
Materials and Methods Patients diagnosed with thigh compartment syndrome were analyzed retrospectively at the authors’ level I trauma center from March 2012 to February 2022. Data were collected from medical and radiological records, focusing on demographics, injury details, treatment timelines, and clinical outcomes.
-
Results The cohort included 13 patients (11 males and 2 females) with a mean age of 46 years. Injuries primarily resulted from falls (6 patients) and vehicle accidents (5 patients). Fractures were noted in 11 patients, with seven involving the lower extremities and seven having open fractures; three of these were severe enough to be classified as Gustilo–Anderson type IIIc with associated femoral artery injuries. Time from the injury to fasciotomy ranged from within six hours to more than 24 hours. Fasciotomies were mainly single-sided (10 patients), targeting primarily the anterior compartments, and bilateral in three cases. Wound closures were performed using delayed primary closure (four patients) and partial-thickness skin grafts (five patients). Two patients died from multi-organ failure; other complications included infections (three patients), amputations (three patients), and long-term disabilities like drop foot (two patients), sensory deficits, joint stiffness (eight patients), and fracture non-unions requiring additional surgery (two patients).
-
Conclusion Thigh-compartment syndrome, though infrequent, poses significant risks of mortality and chronic disability. This underscores the importance of prompt diagnosis and intervention.
Introduction
Acute compartment syndrome is a serious surgical emergency that occurs when the pressure within a closed fascial compartment is greater than the perfusion pressure of capillaries.1-4) Acute compartment syndrome in the femoral region is less common than compartment syndrome in other locations, resulting in a relative lack of literature and clinical experience. Acute compartment syndrome can lead to serious complications of irreversible damage, amputation, and death if not treated in a timely manner, such as fasciotomy.5,6)
Acute compartment syndrome of thigh (CST) can be associated with multiple traumas such as fractures, hemorrhagic shock, blunt trauma, or a combination of these factors.7-9) The CST can lead to more serious complications than lower leg compartment syndrome due to the greater muscle mass of the femur compared to other regions, but it is often difficult to treat due to the lack of clinical signs and the lack of well-defined threshold pressures.10)
This study aims to contribute to the understanding of CST by examining the demographic, trauma-related, treatment-related, and outcome-related characteristics of patients diagnosed and treated for CST at a single level I trauma center over the past decade. By studying surgical and subsequent treatment and clinical outcomes, we hope to improve the clinical understanding of CST and provide evidence-based approaches for better patient management.
Materials and Methods
This is a study of patients presenting to a single trauma center. This study was conducted after being approved by the Institutional Review Board (IRB) of Ajou University Hospital (IRB No. AJIRB-MED-OBS-17-17), and written patient informed consent was waived by the IRB as a retrospective medical record study. The study was conducted on trauma patients who were diagnosed and treated for traumatic acute CST from March 2012 to February 2022 at Ajou Trauma Center, using the medical records and radiological examination records of the patients, and the demographic information such as age and sex of the patients; preexisting medical history; trauma-related information such as mechanism of injury and comorbidities; treatment-related information such as timing of surgery, fascial incision method, timing and method of suturing; and follow-up clinical outcomes through outpatient records were investigated and analyzed.
Statistical analysis was performed using SAS statistical software package for Windows (ver. 9.4; SAS Institute).
Results
There were 13 patients included in the study, 11 males and 2 females, with a mean age of 46 years (range, 22-56 years). The mechanisms of injury were varied, but falls (6 patients) and motor vehicle accidents (5 patients) were the most common. Fractures were found in 11 of the 13 patients, 7 of whom had an anterior subtrochanteric fracture of the femur, 5 of the 13 fractures were open, and 3 of the open fractures had femoral artery injuries corresponding to Gustilo–Anderson type IIIc. The Injury Severity Score was found to be 17.8±3.5 (range, 16-36). Serum creatin-phosphokinase levels were elevated at 22,076±7,524 mU/mL and myoglobulinuria was confirmed in 4 patients at the time of diagnosis of acute compartment syndrome (Table 1).
The time between the diagnosis of CST and fasciotomy was greater than 24 hours in 7 patients, 12 to 24 hours in 3 patients, and less than 6 hours in 3 patients. The fasciotomy was performed in 10 patients with a single lateral incision and in 3 patients with bilateral incisions on the medial and lateral sides. Of the 10 patients with a single lateral incision, 7 decompressed only the anterior compartment, and 3 incised both the anterior and posterior compartments. The incision wound was closed with delayed primary repair in 4 cases, split thickness skin graft repair in 5 cases due to failure to close the wound, and free flap surgery in 1 case.
Of the 13 patients, two died from complications during trauma intensive care unit care, and both were presumed to have died from multiple organ failure. Other in-treatment complications included three infections (two suture wound skin infections and one deep infection) and three lower extremity amputations (two hip bisections and one femoral amputation).
Eleven patients were followed up for more than one year, and only two of the eleven recovered without significant sequelae, with complications of foot drop (two patients), decreased joint range of motion (eight patients), skin hypoesthesia, and fracture nonunion (two patients) identified during follow-up. Two of the nonunion were treated with medullary bone marrow replacement and both were able to achieve osseointegration (Table 2).
Discussion
Acute CST is a serious clinical condition that occurs infrequently among trauma patients and can result in high mortality and serious complications if appropriate treatment is delayed.8) This study aimed to improve our understanding of this rare condition by analyzing the clinical characteristics and treatment outcomes of CST. In particular, this study focused on the various factors associated with the development of CST and the impact of the timing of surgical intervention on clinical outcomes.
The analysis showed that the occurrence of CST was strongly associated with a significant injury, such as a femur fracture. This was evidenced by the fact that 13 of the 13 patients diagnosed had a concomitant fracture of the femur, with 7 fractures of the anteroinferior trochanter being more common than other fractures. Previous studies have shown that early total care for femur fractures, with surgery performed within 24 hours of presentation, is highly effective in improving patient recovery and preventing complications.11) It is significant that seven of the patients diagnosed with CST were diagnosed after 24 hours, six of whom had femur fractures, and no initial damage control such as external immobilization was performed. Failure to stabilize a femoral fracture with external fixation, traction, or early prevention after femoral injury may increase the likelihood of CST.
High-energy injury to the femur results in a rapid increase in internal pressure that can cause tissue anoxia and muscle ischemia, along with the development of typical CST symptoms such as pain, paresthesias, and even numbness.2) Therefore, it is important to make an accurate diagnosis and perform a fasciotomy as soon as possible after the injury. The data collected in this study suggests that prompt therapeutic intervention when CST occurs can significantly improve patient outcomes. In particular, prompt surgical intervention was associated with a significantly reduced risk of tissue damage and long-term complications.9,12,13) However, delayed treatment can lead to irreversible tissue damage and death, so prompt medical attention is essential when CST is suspected.
This study also provides important information about the clinical features and treatment strategies commonly observed in patients with CST. CST can be commonly triggered by several traumatic factors, such as fracture, shock, and anticoagulation therapy, and these factors have a significant impact on disease development and clinical outcome. Therefore, the possibility of post-traumatic CST requires prompt diagnosis and an aggressive treatment approach. In addition, fasciotomy is an essential procedure in the treatment of CST, which can promote pain relief and functional recovery if performed in a timely manner, and the method and timing of wound closure after fasciotomy plays an important role in long-term tissue repair and functional recovery.14)
One of the key challenges in the management of acute CST is the high clinical variability of this condition. The insights gained from this study can contribute to the development of clinical guidelines for the effective management of CST, and future studies will need to develop standardized treatment protocols based on these clinical guidelines. This will lead to improved prevention, early diagnosis, and treatment outcomes for CST.
Conclusion
In conclusion, this study provides a deeper understanding of the clinical characteristics and treatment outcomes of acute CST, which may provide important guidance in the diagnosis and management of CST. This study will also contribute to increasing awareness of this rare condition and help clinicians respond more effectively.
Acknowledgments
The abstract of this paper was presented at the 50th Academic Conference of the Korean Fracture Society in 2024.
Table 1.
Clinical Presentation (n=13)
Table 2.
Complications after Acute Compartment Syndrome of Thigh
- 1. Hope MJ, McQueen MM: Acute compartment syndrome in the absence of fracture. J Orthop Trauma, 18: 220-224, 2004.ArticlePubMed
- 2. Tillinghast CM, Gary JL: Compartment syndrome of the lower extremity. In: Mauffrey C, Hak DJ, Martin III MP eds. Compartment syndrome: a guide to diagnosis and management. Springer: 67-81, 2019..
- 3. Duckworth AD, McQueen MM: The diagnosis of acute compartment syndrome: a critical analysis review. JBJS Rev, 5: e1. 2017.Article
- 4. McQueen MM, Duckworth AD: The diagnosis of acute compartment syndrome: a review. Eur J Trauma Emerg Surg, 40: 521-528, 2014.ArticlePubMedPDF
- 5. Gorczyca JT, Roberts CS, Pugh KJ, Ring D: Review of treatment and diagnosis of acute compartment syndrome of the calf: current evidence and best practices. Instr Course Lect, 60: 35-42, 2011.PubMed
- 6. Zhang D, Janssen SJ, Tarabochia M, von Keudell A, Chen N: Risk factors for death and amputation in acute leg compartment syndrome. Eur J Orthop Surg Traumatol, 30: 359-365, 2020.ArticlePubMedPDF
- 7. McCaffrey DD, Clarke J, Bunn J, McCormack MJ: Acute compartment syndrome of the anterior thigh in the absence of fracture secondary to sporting trauma. J Trauma, 66: 1238-1242, 2009.ArticlePubMed
- 8. Ojike NI, Roberts CS, Giannoudis PV: Compartment syndrome of the thigh: a systematic review. Injury, 41: 133-136, 2010.ArticlePubMed
- 9. Verwiebe EG, Kanlic EM, Saller J, Abdelgawad A: Thigh compartment syndrome, presentation and complications. Bosn J Basic Med Sci, 9 Suppl, 1: S28-S33, 2009.
- 10. Rameder P, Schmidt R, Machold W, et al: Epidemiology, treatment and outcome after compartment syndrome of the thigh in 69 cases: experiences from a level I trauma centre. Injury, 50: 1242-1246, 2019.ArticlePubMed
- 11. Nicola R: Early total care versus damage control: current concepts in the orthopedic care of polytrauma patients. ISRN Orthop, 2013: 329452, 2013.ArticlePubMedPMCPDF
- 12. Knab LM, Abuzeid A, Rodriguez H, Issa N: Thigh compartment syndrome in urban trauma: bullets to blame, not collisions. J Surg Res, 185: 748-752, 2013.ArticlePubMed
- 13. Solasz S, Ganta A, Robitsek RJ, Egol KA, Konda S: Thigh compartment syndrome: outcomes in an urban level 1 trauma center. Injury, 55: 111331, 2024.ArticlePubMed
- 14. Wiger P, Tkaczuk P, Styf J: Secondary wound closure following fasciotomy for acute compartment syndrome increases intramuscular pressure. J Orthop Trauma, 12: 117-121, 1998.ArticlePubMed
References
Figure & Data
REFERENCES
Citations
Citations to this article as recorded by 
ePub Link
Cite
XML DownloadAcute Compartment Syndrome of Thigh: Ten-Year Experiences from a Level I Trauma Center
Acute Compartment Syndrome of Thigh: Ten-Year Experiences from a Level I Trauma Center
| Variable | Value |
|---|---|
| Age (yr) | 46 (22-56) |
| Sex | |
| Male | 11 (84.6) |
| Female | 2 (15.4) |
| Fracture | 11 (84.6) |
| Subtrochanteric | 7 (53.8) |
| Open fracture | 5 (38.5) |
| Gustilo–Anderson type IIIc | 3 (23.1) |
| Injury mechanism | |
| Fall down | 6 (46.2) |
| Traffic accident | 5 (38.5) |
| Hit by object | 2 (15.4) |
| Injury Severity Score | 17.8 (16-36) |
| Time to fasciotomy (h) | |
| >24 | 7 (53.8) |
| 12-24 | 3 (23.1) |
| <6 | 3 (23.1) |
| Serum CPK (mU/mL) | 22,076±7,524 |
| Myoglobulinuria | 4 (30.8) |
| Faciotomy method | |
| Lateral single incision | 10 (76.9) |
| Lateral/medial double incision | 3 (23.1) |
| Wound closure | |
| Primary delayed closure | 4 (30.8) |
| Split-thickness skin graft | 5 (38.5) |
| Free flap | 1 (7.7) |
| Value | |
|---|---|
| Mortality | 2 (15.4) |
| Infection | |
| Superficial | 2 (15.4) |
| Deep | 1 (7.7) |
| Amputation | |
| Hip disarticulation | 2 (15.4) |
| Above knee | 1 (7.7) |
| Restriction of the knee range of motion | 8 (61.5) |
| Foot drop | 2 (15.4) |
| Nonunion | 2 (15.4) |
Table 1. Clinical Presentation (n=13)
Values are presented as mean (range), number (%), or mean±standard deviation. CPK: creatin-phosphokinase.
Table 2. Complications after Acute Compartment Syndrome of Thigh
Values are presented as number (%).
