Compartment Syndrome of the Thigh

Johnathan Cooper

What is it?

• Compartment syndrome is a condition in which increased pressure (by blood, edema, or muscle volume) within a closed fascial space compromises the circulation and reduces perfusion to the tissues contained within this space.

Three Compartments in Thigh

Anterior compartment most likely to develop compartment syndrome

How is it caused?

• The most common cause of thigh compartment syndrome is blunt trauma along with a femoral fracture

• Occurs the majority of the time• There are multiple other ways however that

TCS can be caused including exercise-induced TCS, vascular injuries, and reperfusion injuries

How is TCS Diagnosed Clinically?

Initial Features• Pain out of proportion to

injury or surgery• Tense swelling of leg• Pain with passive stretch

Late Findings (5 P’s)• Pain• Pallor• Paresthesia• Pulselessness• Paralysis

Anterior Compartment Clinical Presentation

Pressure Measurement used to Assist Diagnosis

• Pressure measurements are helpful when the patient is unresponsive

• Absolute compartment pressure of 30 mmHg• OR• ∆P within 30mmHG of diastolic blood pressure• ∆P =(Diastolic Blood Pressure) – (Intra-

compartmental Pressure)

Risk Factors

Developing TCS• Young age• Male• Bleeding disorder• On anticoagulants

Misdiagnosis of TCS• Altered conscious level• Patient on anesthesia• Nerve injuries

TCS is a surgical emergency

• If left untreated, within 6 hours, it can lead to tissue death/ necrosis

• Ischemic changes may be present in a 4 to 6 hour time frame when DBP approached 20 mmHg

• 8 hours of increased ICP to within 20 mmHg of DBP is critical threshold for ischemic muscle necrosis

• Early diagnosis and treatment is critical

Single vs. Double Incision Thigh Fasciotomy

• Single incision results in a lower complication rate 12% compared to anywhere from 30-70% as reported in double incision case reviews

• *based on 17 patient case review• Faster to make one incision than two incisions• One fewer wound to close afterwards

How is Single Incision Thigh Fasciotomy Performed?

• The skin and subcutaneous tissues are incised beginning around the interochanteric line and extending to the lateral epicondyle, exposing the iliotibial band

Incision cont.

• Through this incision, the iliotibial band and fascia of the vastus lateralis are incised the full length of the skin incision to decompress the anterior compartment.

• Posterior compartment is decompressed by reflecting the vastus lateralis muscle medially to expose the lateral intermuscular septum, which is incised the length of the skin incision

• Hematoma is not disturbed

Pie-CrustingAfter longitudinal incision, the fascia lata is incised with anteriorly and posteriorly oriented rents, perpendicular to the main incision

This pie crusting of the fascia lata is important for two reasons 1. It allows a more complete

release of the muscle 2. You avoid incision of the muscle

by the tense fascial boundaries.

How is the Wound Closed

• Wound is not closed right after surgery• Wound is typically closed *7-10 days later, but

VAC can close wound a couple days post-op• Techniques include:• Continuous traction (Tissue expander)

technique• Split-thickness skin grafting• Vacuum assisted closure

Case Study

• Patient on anticoagulation drugs • Developed thigh and lower leg compartment

syndrome• Single incision thigh and lower leg fasciotomy

performed• Tissue expansion wound closure

Video

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