Acute compartment

syndrome of the thigh sports-related injuries not associated with

in

femoral fractures WILLIAM A. WINTERNITZ,

From the

Many

athletes

are

JR.,*† MD, JEFFRY A. METHENY,* MD, AND LARRY C. WEAR,‡

*Department of Orthopaedic Surgery, University of California at Davis, Davis California, and ‡San Jose, California

involved in sports that

can

result in

days later. His

trauma to the limbs. Sometimes, from the resultant muscle trauma and bleeding, a compartment syndrome develops in the lower leg or forearm. We present two athletes with acute

course

was

complicated by

a

superficial

infection that was treated by local debridement and antibiotics. The patient regained full range of motion of the knee and returned to recreational sports 6 months after surgery. Orthotron (Lumex, Bayshore, NY) testing 18 months after surgery revealed greater peak quadriceps and hamstring torques on the involved side than on the uninvolved side at speeds of both 90 and 240 deg/sec. Endurance testing at 240

compartment syndrome of the quadriceps compartment. They were treated with prompt compartmental decompressive fasciotomy and subsequently recovered.

deg/sec was equal for both legs (Table 1).

CASE REPORTS

Case 2 Case 1 A

64-year-old Class A Senior Tennis Tournament player presented to us after he was involved in a bicycle accident. The exact mechanism of the injury was unknown, although the patient was thrown to the ground during the accident and received a direct blow to the head, shoulder, and right thigh. He had a temporary loss of consciousness before being transported to the hospital. At admission, he was alert and oriented, with normal vital signs except for a blood pressure of 200/100. Physical examination revealed a painful and tense right lateral thigh. Pain was increased with passive flexion of the knee. There was a slight decrease in sensation over the distal lateral thigh. Extension of the knee was rated

A 20-year-old college student was struck on the lateral aspect of the right thigh with a lacrosse stick and presented for treatment. He experienced initial minor pain that became progressively worse over the next 4 hours. At the time of admission, physical examination revealed a tense anterior thigh and his quadriceps function was rated 3+ to 5+ on a scale of 1 to 5. Sensation was normal in the leg and there was pain in the quadriceps muscle with passive flexion of the knee. Pulses in the right foot were within normal limits. Three consecutive pressures, using the Whiteside technique,l° were measured at 60 mm Hg. Roentgenograms of the right femur were negative and the preoperative hemoglobin level of 13.5 g/dL dropped to 9.5 g/dL postoperatively. Coagulation tests were normal. Approximately 12 hours after the injury, the patient underwent a fasciotomy of the right quadriceps compartment, which revealed swollen vastus lateralis, rectus femoris, and vastus intermedius muscles. The wound was closed 8

TABLE 1 Orthotron results

t Address correspondence and reprnt requests to’ William A Wntermtz, Jr, MD, 2031 Anderson Road, Smte A, Dams, CA 95616.

a

476

Peak torques

(foot-pounds).

477 a 2+ to 3+ (of 5+). Pulses in the foot were normal. Compartment pressures in the lateral thigh were read at 50 mm Hg proximally and 35 mm Hg distally using a hand-held

intracompartmental pressure monitoring system (Stryker Corp, Kalamazoo, MI). Roentgenograms of the femur were normal, as were coagulation tests. Preoperatively the hemoglobin count was measured at 14.3 g/dL and dropped postoperatively to 9.5 g/dL. A continual-monitoring thigh cannula was inserted into the lateral thigh and revealed consistent values in the mid-30s mm Hg range. The patient was treated with hydralazine for his hypertension and his blood pressure decreased to 166/100 by 4 hours after admission. Repeat pressures in the lateral thigh were measured at 58 mm Hg proximally and 35 mm Hg distally. Nine hours after the injury, the patient underwent a fasciotomy of the right quadriceps compartment because of consistently elevated compartment pressures and the lack of clinical improvement. The wound was closed 8 days later. The patient’s recovery was complicated by deep venous thrombosis in the popliteal area and the thigh, requiring anticoagulation. He returned to cycling at 3 months and competitive tennis by 6 months after surgery. Orthotron testing performed 14 months after surgery revealed greater peak hamstring and quadriceps torques on the involved versus the uninvolved sides at both 90 and 240 deg/sec (Table 1). He had full range of motion in both knees.

DISCUSSION We have reported on two athletes with compartment syndrome of the thigh secondary to blunt trauma not associated with a femoral fracture. The indications for fasciotomy in these patients were consistent with those described in the literature.’-9 Mubarak et aI.6 cited 30 mm Hg as the indication for fasciotomy because normal capillary pressure in dogs and cats is from 20 to 30 mm Hg; beyond this level, pain and paresthesia occur. Matsen et al.’ chose 55 mm Hg as the indication for fasciotomy because all of the patients in their series who had maximum intracompartmental pressures of 45 mm Hg or less did not require fasciotomy and demonstrated no residuals of a compartment syndrome at

Clinically, the two patients in our study had intense pain in the involved compartments, increased pain with passive flexion of the knee, and marked extensor weakness. One patient had locally decreased sensation in the distribution of the superficial femoral nerve. Peripheral pulses were intact in both patients. Maximal compartmental pressures were read at 50 and 60 mm Hg. We treated our patients with release of the quadriceps compartment and local epimysiotomy of the involved quadriceps muscles. In each case the wounds were closed on a delayed basis. Muscle function testing 18 months postoper-

atively revealed greater peak torques on the involved versus the uninvolved side. No evidence of myositis ossificans was noted. CONCLUSIONS in the thigh condition that can be associated with femoral fractures, crush syndromes, and blunt trauma. The exact amount of tissue pressure in the thigh that warrants a fasciotomy is still somewhat questionable. Compartmental release of the quadriceps mechanism should be entertained when early signs of progressive pain, a clinically tense compartment, and pain with passive motion are noted. Delayed signs of decreased sensation in the distribution of the femoral nerve and quadriceps weakness add further urgency to this decision. We recommend that a fasciotomy be performed when clinically indicated if pressures are noted in the 50 to 60 mm Hg range and diastolic blood pressure is within normal limits. Acute compartment syndrome of the thigh is a true orthopaedic emergency that can be successfully treated with a prompt fasciotomy and delayed wound closure. We found that athletes can expect to return to full activities if given timely treatment and vigorous rehabilitation.

Compartment syndrome requiring fasciotomy is

a

rare

ACKNOWLEDGMENTS We thank Joan

Gregg, RPT, Bud Cassell, RPT, ATC, and Terry Harrell, RPT, ATC, for their help with the Orthotron testing.

followup. The threshold pressures for decompression of the thigh variable and range from 30 to 80 mm Hg.1,3-6,8 Irreparable damage to the involved muscles was found to occur with pressures greater than 55 mm Hg.5 The functional results after decompression of the thigh were also variable. Schwartz et al.’ reviewed the cases of two patients with compartment syndrome of the thigh. One patient had normal functional results at 2-year followup and the other one had persistent motor and sensory deficits. An et a1.2reported one case of acute compartment syndrome of the quadriceps muscle. Six weeks after surgery the patient had 5+/5+ quadriceps function. Klasson and Vander Schilden4 reported on one patient who had equal quadriceps strength in both legs 14 weeks postoperatively.

REFERENCES

are

1

2

3 4

5

6

Stirling AJ, Crawshaw CV, et al: Intracompartmental pressure monitoring of leg injuries An aid to management J Bone Joint Surg 67B 53-57, 1985 An HS, Sampson JM, Gule S, et al: Acute compartment syndrome of the thigh A case report and review of the literature J Orthop Trauma 1. 180182,1989 Clancey GJ: Acute posterior compartment syndrome in the thigh. A case report J Bone Joint Surg 67A: 1278-1280, 1985 Klasson SC, Vander Schilden JL Acute anterior thigh compartment syndrome complicating quadriceps hematoma Two case reports and review of the literature Orthop Rev 19: 421-427, 1990 Matsen FA III, Winquist RA, Krugmire RB: Diagnosis and management of compartmental syndromes J Bone Joint Surg 62A 286-291, 1980 Mubarak SJ, Owen CA, Hargens AR, et al Acute compartment syndromes Diagnosis and treatment with the aid of the wick catheter J Bone Joint Surg 60A. 1091-1095, 1978 Allen MJ,

478 7

Rooser D Quadriceps contusion with compartment syndrome. J Bone Joint Surg 62A. 286-291 8 Schwartz JT Jr, Brumack RJ, Lakatos R, et al Acute compartment : 392syndrome of the thigh. A spectrum of injury J Bone Joint Surg 71A

400, 1989 9. Tarlow SD, Achterman CA,

Hayhurst J,

et al Acute

compartment syn-

in thigh complicating fracture of the femur A report of three cases J Bone Joint Surg 68A 1439-1443, 1986 10 Whitesides TE Jr, Harada H, Morimoto K Compartment syndromes and the role of fasciotomy, its parameters and techniques Instr Course Lect

drome

26 179-196,1977

Acute compartment syndrome of the thigh in sports-related injuries not associated with femoral fractures.

Acute compartment syndrome of the thigh sports-related injuries not associated with in femoral fractures WILLIAM A. WINTERNITZ, From the Many at...
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