Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries

Trocar injury of the retroperitoneal vessels followed by life-threatening postischemic compartment syndrome of both lower extremities

BACKGROUND

Lesions of the intra-abdominal organs and vessels caused by trocars and Verres needles are rare but serious complications during laparoscopic surgery.

REPORT

We report an unusual case of left common iliac artery and inferior vena cava injury during laparoscopy. This lesion was followed by a bilateral postischemic compartment syndrome of the lower extremities. The patient sustained massive rhabdomyolysis, renal failure, peroneal nerve palsy, and functional loss of the lower extremities.

CONCLUSION

Postischemic tissue swelling should be recognized as early as possible because it is a life-threatening condition that necessitates immediate treatment.

Femoral nerve block for diaphyseal and distal femoral fractures in the emergency department

BACKGROUND

Diaphyseal and distal femoral fractures are painful injuries that are frequently seen in patients requiring a trauma work-up in the hospital emergency department prior to definitive management. The purpose of this study was to determine whether a femoral nerve block administered in the emergency department could provide better pain relief for patients with femoral fractures than currently used pain management practices.

METHODS

Patients who presented with an acute diaphyseal or distal femoral fracture were identified as potential candidates for this study. Eligible patients were randomized by medical record number to receive either (a) the femoral nerve block (20 mL of 0.5% bupivacaine) along with standard pain management or (b) standard pain management alone (typically intravenous narcotics). The pain was assessed with use of a visual analog scale at the initial evaluation and at five, fifteen, thirty, sixty, and ninety minutes following the initial evaluation. Fifty-four patients were enrolled in the study from April 2005 to May 2006. Thirty-one patients received a femoral nerve block, and twenty-three patients received standard pain management alone.

RESULTS

Baseline scores on the visual analog pain scale did not differ between the groups at the initial evaluation. The patients who received a femoral nerve block (along with standard pain management) had significantly lower pain scores at five, fifteen, thirty, sixty, and ninety minutes following the block than did the patients who received standard pain management alone (p < 0.001). The score on the visual analog pain scale across these time-points was an average of 3.6 points less (on a 10-point scale) for those who received the block. There were no infections, paresthesias, or other complications related to the femoral nerve block.

CONCLUSIONS

The acute pain of a diaphyseal or distal femoral fracture can be significantly decreased through the use of a femoral nerve block which can be administered safely in the hospital emergency department.

Compartment syndrome as a complication of a stab wound to the thigh: a case report and review of the literature

Acute compartment syndrome of the thigh is a rare but potentially devastating condition, in which the pressure within the osseofascial compartment rises above the capillary perfusion gradient, leading to cellular anoxia, muscle ischaemia and death. Early diagnosis and treatment is essential to prevent long term disability. It is most often associated with crush injuries and femoral fracture. We present a previously unreported case of thigh compartment syndrome following a stab injury, treated by emergent fasciotomy.

Compartment syndrome of the thigh in an infant: a case report

Compartment syndrome of the thigh in children is rare. We report a case of compartment syndrome of the thigh in an infant with a femur fracture resulting from suspected nonaccidental trauma. The delayed presentation of this injury may have been contributory to the development of compartment syndrome. The subtle physical findings in this case underscore the need for a high index of suspicion in making the diagnosis of compartment syndrome. The complete recovery of muscle function, even in the presence of significant tissue damage, is noteworthy and suggests that infants have a greater physiologic ability to recover in comparison with adults.

Conservative treatment of an acute compartment syndrome of the thigh

Compartment syndromes of the thigh after blunt trauma without any fracture are rare. Most surgeons recommend operative treatment. There are different rules for compartment syndromes of the thigh in young athletes after blunt trauma compared to compartment syndromes at other locations [(1) the large volume of the quadriceps muscle, (2) its relatively elastic fascia, (3) the direct proximal contact to the hip muscles which allows extravasation of fluid out of the compartment)]. We present a case of conservative treatment of elevated intra-compartmental pressure (ICP) of the anterior thigh after blunt trauma and the follow-up until return to sport. Conservative treatment of a compartment syndrome of the thigh after blunt trauma in a young patient without fracture or vascular damage was successful without short-term sequelae. Recovery of muscle strength is delayed but return to sport is possible. Depending on the severity the diagnosis and follow-up with ICP measurements and MRI is necessary. There is a very good chance for excellent outcome without any risk of surgery. However, a long healing time is possible.

Long term results of compartment syndrome of the lower limb in polytraumatised patients

Acute compartment syndrome represents a severe complication after trauma of the lower extremity. To date, there is limited knowledge about the outcome of compartment syndrome of the lower limb in patients with multiple injuries. We hypothesised that multiple injuries worsen the long term results of compartment syndrome of the lower leg. Patients who underwent fasciotomy for established compartment syndrome of the lower leg from 1999 to 2004 in our level 1 trauma centre were included. Demographic data, additional injuries (Injury Severity Score) and method of treatment were analysed. Outcome assessments included clinical examination and isokinetic strength testing of plantar flexion and dorsal extension at two different angular velocities (60 degrees /s; 120 degrees /s). The mean age was 38.0+/-4.4 years at the time of injury; males were affected twice as often as females. The mean ISS of patients with multiple injuries was 20.2+/-2.3 points. The time between admission and surgical treatment of compartment syndrome was extended in patients with multiple injuries (38.6+/-13.8h versus 13.2+/-3.8h; p=0.04). At follow-up, 15.4% of all patients complained of pain at rest and 26.9% reported pain on exertion. A significant reduction of torque and work was found in the dorsal extensors on the injured side (p<0.05). Polytraumatised patients did not show extended weakness compared to those with isolated injuries. No difference was seen between the two groups regarding pain and function. Polytraumatised patients did not suffer from worse long term effects regarding sensory or motor deficits. Associated injuries did not seem to influence the outcome of the compartment syndrome.

Overdistraction of the Fracture Eases Reduction in Delayed Femoral Nailing: Results of Intraoperative Force Measurements

BACKGROUND

(Initial) primary external fixation of femoral shaft fractures followed by secondary intramedullary nailing is a concept of damage control orthopedics. We hypothesized that external fixation with overdistraction of the fracture might reduce reduction forces and shorten reduction time during the secondary nailing.

METHODS

An experimental study on seven patients with eight fractures of the femoral shaft was conducted. Intraoperative reduction forces were determined in all patients using a load cell. The amount of distraction was measured on the latest radiographs before nailing. The reduction time was recorded as an indirect indicator of the intricacy of reposition. Reduction forces and reduction times were compared between those fractures fixed with shortening (Group A) and those fixed in distraction (Group B).

RESULTS

Three femurs showed some shortening and five femurs showed some distraction within the fracture. The maximum measured distraction force along the shaft axis was 396 N. On average the maximal force was 336 N (+/- 51.9 N) in Group A and 200 N (+/- 43.1 N) in Group B. This difference is statistically significant (p = 0.007). The average reduction time was 28.3 minutes (+/- 21.8 minutes) in Group A and 5.8 minutes (+/- 4.0 minutes) in Group B. This difference shows a trend toward significance (p = 0.056).

CONCLUSION

Fracture shortening leads to higher restraining forces and consequently prolonged reduction time in delayed nailing. Overdistraction should be performed as soon as possible under careful soft-tissue monitoring.

Acute compartment syndrome complicating an intramuscular haemangiosarcoma in a dog

Acute compartment syndrome in dogs is a rare complication of muscle trauma, but it has not been previously reported as a consequence of neoplasia in dogs. This case report describes the occurrence of a compartment syndrome of the femoral compartment in an 11-year-old, male, mixed-breed dog caused by acute bleeding of an intramuscular haemangiosarcoma. The compartment syndrome was relieved by immediate fasciotomy. The dog was euthanased following acute recurrence of clinical signs seven weeks after surgery.

Compartment syndrome following total knee arthroplasty: a report of seven cases

Compartment syndrome is a rare complication of total knee arthroplasty that requires early recognition and prompt decompression in order to prevent long-term disability. We have found only one previous case report in the literature. We present a series of seven cases from four hospitals and five surgeons. Six of the cases resulted in the loss of at least one compartment, and one resulted in amputation. Four of the cases resulted in legal action. We suggest that important risk factors contributing to the development of this condition include complex surgery, soft-tissue compromise, previous surgery, and possibly vascular disease. Delay in the diagnosis and hence delay in decompression was common in our series, and in five cases appeared to be related to the use of a postoperative epidural infusion for pain relief. The presence of associated neurological compromise may have also been a significant factor in the delay to diagnosis in two cases.

Acute compartment syndrome of the thigh in a high school soccer player: indications for expedient action

Compartment syndrome in the lower leg, most commonly related to exertion, has been well documented in athletes. However, compartment syndrome resulting from trauma is rare in athletes, as in this case of a 17-year-old male goalie who sustained a direct blow to his thigh during a soccer game. He was successfully treated with early fasciotomy and delayed wound closure, and he made a full recovery.

Acute compartment syndrome of the thigh in a football athlete: a case report and the role of the vacuum-assisted wound closure dressing

We present a case of compartment syndrome of the thigh due to blunt injury in a Division I American football player managed with fasciotomy and vacuum-assisted wound closure. This case report discusses the vacuum-assisted wound closure dressing as an alternative to more traditional closure techniques such as suture retention devices and split-thickness skin grafting. We feel that any surgeon involved in performing fasciotomies should be familiar with this increasingly used closure device and its potential complications.