CJ
Tollan .
West of Scotland Basic Surgical Trainee, SHO II Plastic Surgery, Glasgow Royal Infirmary, Glasgow
Address: Flat 3/1, 4 Dudley Drive, Glasgow, G12 9SD, UK
Tel: 07989073385
Email: cj_tollan@hotmail.com
D J M Macdonald MBChB, MRCS (Glasg), BSc Hons, Specialist Registrar, Department of Orthopaedic Surgery, Western Infirmary, Glasgow.
Michael P Kelly FRCS (Orth), Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Western Infirmary, Glasgow.
SMJ 2008 53(4): 10
Abstract
Thigh
compartment syndrome is a relatively rare but potentially devastating condition.
We present three cases in semi-professional soccer players and demonstrate that
satisfactory results can be obtained with timely surgical intervention.
Clinicians and team doctors should have a high index of suspicion for thigh
compartment syndrome following blunt trauma and should be aware that it can
develop many hours or days after injury.
Key Words: Compartment
syndrome, soccer, thigh
Introduction
We
present three cases of compartment syndrome of the thigh in semi professional
soccer players who presented to our orthopaedic trauma unit. All played as
midfielders and sustained their injuries during challenges for possession of the
ball during competitive matches. None of the players were able to continue play
at the time of their injury.
Case
1
A 20 year old who sustained a direct blow to his left thigh during a challenge. He attended the local emergency department where he was assessed and then discharged with the advice to rest. Over the following 48 hours his pain and swelling worsened despite total rest. He then presented back to hospital by which time he was noted to have tense swelling of his anterior and lateral left thigh with severe aggravation of the pain on passive flexion at the knee. There was no distal neurovascular deficit. He required intravenous opiates for analgesia and a diagnosis of compartment syndrome was made on clinical grounds. He underwent emergency fasciotomy in theatre where a large haematoma was found deep to fascia lata. No active bleeding was observe and the wound was left open and covered with a sterile dressing. After 48 hours of bed rest with leg elevation he returned to theatre for inspection and the swelling was found to have subsided. Primary wound closure was performed.
He remained in hospital for a further 6 days for bed rest and physiotherapy. Following discharge from hospital he underwent intensive physiotherapy and returned to the same level of competitive semi-professional soccer 5 months later. Six months post injury he had a full range of movement in his hip and knee and on stressing has quadriceps muscle group he had an obvious muscle herniation under the surgical scar.
He
felt that he had ‘lost a couple of yards’ when sprinting and he was also
concerned about the cosmetic deformity and was keen for surgery to improve the
appearance.
Case
2
A 21 year old male who was involved in a challenge where he fell to the ground and an opposing player landed on top of his right thigh. He developed immediate pain and swelling which worsened over the following 30 minutes, he became unable to weight bear before attending the emergency department. On examination he was distressed due to the pain and had a tense and swollen thigh. Distal pulses were present but there was paraesthesia over the lateral aspect of his thigh and calf. He required intravenous opiates and was then taken to theatre for emergency fasciotomy. Immediate pre-operative investigations revealed Hb 15.1 g/dl, CK 351 iu/L, with normal Urea and electrolytes and normal clotting profile. At theatre a massive haematoma was evacuated from the anterior compartment and several bleeding vessels required cautery (Fig 1). Post operatively he continued to bleed into his dressings and he became tachycardic and oliguric, following emergency transfusion of 4 units of packed red cells, his haemoglobin was 8.8 g/dl. He was taken back to theatre where a bleeding vessel was identified and haemostasis was achieved. He received a total of 6 units of packed red cells. Two further wound inspections were performed and the wound was gradually closed using a ‘boot lace’ technique which enabled opposition of the wound edges and primary closure (Figs. 2 and 3).
He
was discharged after 14 days stay and attended intense physiotherapy for 6
months. At follow up at 6 months he had a full range of movement at his hip and
knee. He felt he had regained his level of endurance fitness, however he was not
as fast at sprinting and was no longer able to compete at a high level. He
therefore retired from semi-professional sport. He also complained of the
cosmetic deformity due to muscle herniation, but did not want further surgery to
repair this defect.
Figure 1. Fasciotomy with bulging vastus lateralis visible.
Figure 2. Bootlace technique for gradual wound approximation
Figure 3. Final closure of the wound
Case
3
A 25 year old was struck by an opponent’s head on his right anterior thigh, which resulted in his opponent being knocked unconscious. His injury was immediately treated with ice. He returned home after the match but the pain and swelling increased and 6 hours after the injury he was unable to weight bear and attended hospital. On examination he was haemodynamically stable but had a tense swelling of the anterior aspect of his lower thigh. He was unable to actively flex or extend his knee, could not straight leg raise and passive movement evoked severe pain. Anterior thigh compartment pressure was checked and it was raised at 48 mmHg with a blood pressure of 137/80 mmHg.
At
emergency fasciotomy there was a large haematoma deep to vastus lateralis which
was evacuated. Post operatively his Hb had dropped to 7.9 g/dl and his CK was
928 iu/L and he was transfused 3 units of packed red cells. He was taken back to
theatre on days 2, 4 and 6 post injury for further wound washout and gradual
approximation of the skin edges again using a boot lace technique. Nine days
post fasciotomy the wound was successfully closed and there was no evidence of
muscle necrosis. He was discharged on day 11 and underwent an intensive
physiotherapy programme. By six months he was back to competitive soccer without
any subjective loss of his preinjury form.
Discussion
Compartment
syndrome has been defined by Murbarak et al (1976) as ‘increased tissue
pressure in a closed fascial space……compromising the circulation to the
nerves and muscles within the involved compartment’1. Acute
compartment syndrome is a true orthopaedic emergency and delayed diagnosis can
result in severe permanent sequelae including paralysis, contractures and even
limb amputation.
Aetiology
Most
compartment syndromes are associated with traumatic insults (e.g. fractures)
although aetiological factors also include fracture surgery, soft tissue injury
including crush injuries, burns and prolonged limb compression, iatrogenic
injury such as venepuncture in anticoagulated patients, use of pneumatic
antishock garment, casts and dressings, and rarely exercise2-7.
Compartment
syndrome has been reported in the leg and forearm but is less frequently
reported in the thigh due to higher elasticity and the large potential space
available to allow for swelling and an increase in interstitial pressure before
circulation is endangered7-9. The thigh has three compartments,
anterior, medial, and posterior, enclosed by the fascia lata. Most of the
reported compartment syndromes of the thigh are anterior as it is surrounded by
the stiffest walls laterally and medially, and is the most anatomically
vulnerable to contusion.
Diagnosis
Clinical examination is the key to diagnosis of compartment syndrome in the awake cooperative patient, although compartment pressure measurements can be used for additional information. Diagnostic clinical symptoms include thigh pain out of proportion to severity of injury (most consistent), swollen tense thigh with increased circumference, pain with passive stretch, weakness of involved thigh muscle, and sensory or motor deficits in the anatomic distribution of the nerves contained in the involved compartment 4,5,7,10,11. Repeated examinations are recommended. Creatine-phosphokinase levels also reflect the amount of muscular damage. In obtunded patients direct measurement of intracompartmental pressure may be the only reliable means of confirming compartment syndrome5,7,11. In 1989 Schwartz et al considered a pressure of 40mmHg diagnostic of compartment syndrome and pressures of between 30 and 40mmHg potentially resulting in the development of myoneural necrosis7.
Various
absolute and perfusion pressures have been proposed in the literature. The most
recent survey of all Scottish trauma units in 2003 (105 consultants)
demonstrated that the majority supported a perfusion pressure (diastolic
pressure minus tissue perfusion pressure) of less than 30mmHg as their
intervention threshold, with hourly monitoring of pressure desirable11.
Management
There is some debate in the literature with regards conservative as opposed to surgical management for thigh compartment syndrome. Robinson et al advocated conservative management in young patients with an isolated anterior compartment syndrome of the thigh as it limits the infection risk of fasciotomy. They studied six patients who were treated conservatively and showed no limitation of muscle power or joint movement at one year12.
In contrast nearly 50% of a group of 21 patients with acute compartment syndrome of the thigh, studied by Schwartz et al, developed crush syndrome; ischaemic muscle necrosis, myoglobinuria, acute renal failure, and, late complications including muscle contractures7. Conflicting recommendations arise from the notable discrepancy between clinical presentation and outcome. Mistreated compartment syndrome results in muscle necrosis and relies on the limited muscle regenerative power for return of activity which may be insufficient, especially in top athletes. Following these studies, Machold et al made the distinction between ‘impending’ compartment syndrome and ‘manifest’ compartment syndrome to try and clarify management options8. Impending compartment syndrome, ‘pain, palpably hard compartment, no neurological dysfunction and pressure less than 40mmHg’ was treated conservatively including the use of cryotherapy. Development of paraesthesia and paresis signifies ‘manifest’ compartment syndrome: ‘impaired myoneural function and necrosis of the soft tissues when a decompression of the compartment is not achieved’. Treatment of a manifest compartment syndrome is always operative.
A retrospective review of 29 thigh compartment syndromes in 2004 by Mithofer et al demonstrated that the incidence of complications correlated with the time to fasciectomy. Delay greater than 12 hours is associated with a poor outcome5.
Literature
would suggest that the small risk of infection and complications following
fasciotomy is far outweighed by the likelihood of ischaemic contractures,
neuromuscular dysfunction and morbidity in mistreated compartment syndrome1.
In addition, fasciotomy also allows evacuation of haematoma, as found in the
three patients in this series, which has been reported to reduce the incidence
of delayed compartment syndrome and myositis ossificans5.
Prognosis
There
are few studies of compartment syndrome related to sports injuries, although
most state that patients regained their ‘activity level’ in two to six
months4,8,10,13,14.
There
is little information about post rehabilitation level of activity. In 2000
Machold et al reported
a case of a 25-year-old kickboxer who regained the world championship after
suffering a compartment syndrome, caused by multiple blows to his thigh, treated
by fasciotomy8. This shows that outstanding performances can be
achieved by a world-class athlete after operative decompression of a compartment
syndrome of the thigh. In 2002 the case of a 29-year-old international rugby
player was reported who recovered full quadriceps and hamstring strength and a
full active range of motion three months following fasciotomy. Unfortunately he
was only able to return to competitive rugby briefly having developed myositis
ossificans10.
Our
case series also illustrates that with an intensive physiotherapy programme
return to competitive sport is possible, although return to an elite level is
not guaranteed and subjective pre injury performance was only achieved by one
patient. Individual comments were noted concerning decrease in maximal running
speed and the cosmetic deformity resulting from muscle herniation through the
scar.
Prevention
This
series of three patients were semi-professional athletes. It is possible that
the lack of cases reported in the literature of compartment syndrome in
professional athletes reflects reduced incidence perhaps due to immediate
medical care. A study of eight patients with compartment syndrome by Rooser et
al demonstrated
that all patients had continued to play after experiencing very moderate trauma14.
It is advised that ongoing activity after blunt thigh trauma should be stopped
as muscle activity increases the demand for blood flow, increasing compartmental
volume and the risk of compartment syndrome. Although the severity of the three
football players’ injuries prevented them from continuing to play, only one
received immediate care, his injury treated with ice. He subsequently had the
best outcome. No studies have yet been able to demonstrate the significance of
immediate medical care and advice. Poor first aid and alcohol consumption are
likely to exacerbate injury increasing the risk of compartment syndrome13.
It is known that re-bleeding into muscle can occur as late as one week after
injury and therefore the recommended rest period should probably be greater than
this10.
Conclusion
Thigh
compartment syndrome is a relatively rare but potentially devastating condition.
Our three cases in semi-professional soccer players demonstrates that
satisfactory results can be obtained with timely surgical intervention, although
one of our sportsmen was unable to regain adequate form and had to retire from
his soccer career. Clinicians and team doctors should have a high index of
suspicion for thigh compartment syndrome following blunt trauma and should be
aware that it can develop many hours or days after injury.
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