Rare disease
CASE REPORT
Acute compartment syndrome of the thigh in a rugby player Richard David James Smith,1 Holly Rust-March,2 Stefan Kluzek1 1
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK 2 Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK Correspondence to Richard David James Smith, [email protected] Accepted 20 July 2015
SUMMARY In the absence of obvious trauma, diagnosis of acute compartment syndrome (ACS) of the thigh can easily be delayed, as disproportional pain is not always present. We present a case of ACS of the anterior right thigh compartment in a healthy, semiprofessional rugby player with normal coagulation, who sustained a seemingly innocuous blow during a rugby match. Following early surgical fasciotomy, he returned to his preinjury playing standards within 12 months. Our literature review suggests that high muscle mass, young, athletic males participating in a contact sport are mostly at risk of developing ACS of the thigh.
BACKGROUND
To cite: Smith RDJ, RustMarch H, Kluzek S. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015210856
Acute compartment syndrome (ACS) is a medical emergency that can lead to amputation and death.1 ACS is commonly caused by a trauma that damages the muscles and vasculature within an osseofascial compartment and leads to oedema and swelling. The unyielding fascia surrounding the compartment limits this expansion, which increases intracompartmental pressure and reduces the blood supply to the nerves and muscles within. If this pressure exceeds normal capillary perfusion pressure, reduced blood flow can cause ischaemia and tissue necrosis.2 3 ACS is commonly associated with compartments of the lower leg and forearm,4 while ACS of the thigh is relatively rare.4 5 This may be because the thigh compartments are large and encapsulated with dilative fascia,6 and therefore can readily accommodate expansion. Thigh compartments also blend anatomically with the hip,7 which can provide additional space into which the accumulating fluid may be discharged. ACS of the thigh occurs most frequently in the anterior compartment8 due to vulnerability of this site to injury. The aetiology of ACS of the thigh is diverse. Cases of ACS of the thigh have been reported as a result of exercise,7 9–15 deep vein thrombosis,16 drug toxicity,17 18 venomous snake bite,19 anticoagulation therapy,20–22 vascular injury,23–25 continuous external compression,26 use of antishock trousers,27–29 surgical complications30–34 and trauma, both with and without fracture.35–55 Traumatic ACS of the thigh in sport has been reported in football,6 41 44 handball,41 44 American football,38 46 lacrosse,39 softball,54 karate,56 kickboxing43 and in one case of a rugby player.41 This is a rare condition in sport with limited epidemiological data. There is little consensus in the field regarding the precise diagnostic criteria and the
most appropriate treatment technique. Furthermore, little has been done to raise awareness of the risk factors associated with ACS of the thigh in sport.
CASE PRESENTATION Presenting features We present a case of a fit and healthy 37-year-old man who developed ACS of the thigh after sustaining a seemingly innocuous blow to the right anterior lower thigh during a rugby match. The only notable symptom was mild thigh swelling and immediate ache. After initially reporting mild tenderness, his pain gradually developed 1 h after sustaining the injury and he was admitted to the local emergency department 3 h postinjury.
Medical/social/family history The patient had a multiligament surgical reconstruction on his left knee 5 years prior to this presentation. The patient has also had hypertension for the last 4 years, which has been successfully managed pharmacologically. The patient had not sustained any previous injury to his right knee.
INVESTIGATIONS Following admission, the circumference of each thigh was measured. The circumference of the patient’s right mid-thigh was 6 cm larger than his left, and was comparatively more painful and tender. The pressure reading of the right anterior thigh compartment was 38 mm Hg.
TREATMENT A diagnosis of ACS of the right anterior thigh was made and a fasciotomy of the anterior compartment was performed 3 h after admission to the emergency department (figure 1). Following fasciotomy, pressure in the anterior thigh compartment dropped from 38 mm Hg to 17 mm Hg. The patient received a skin graft 8 days following the fasciotomy to cover the large residual wound (figure 2).
OUTCOME AND FOLLOW-UP With regular rehabilitation and physiotherapy supervised by the club physiotherapist, the patient recovered within 6 months. Unfortunately, due to the fasciotomy and skin grafting, the patient reported ongoing patella instability and this reduced the patient’s confidence to participate in rugby training. A reduction of the skin flap with mesh insertion was successfully performed 8 months after the injury to further support the joint. The patient was able to take part in full training 12 months after the injury (figure 3).
Smith RDJ, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210856
1
Rare disease
Figure 1 Right anterior thigh immediately following fasciotomy on the day of injury.
Figure 3 Right anterior thigh 12-months postinjury (after reduction and skin flap insertion).
DISCUSSION ACS of the thigh is a rare diagnosis.4 It is most commonly associated with motor vehicle accidents,4 but has also been reported as a result of trauma in sport.6 38 39 41 43 44 46 54 56
Figure 2 Skin grafted wound 2-months postinjury. 2
Early diagnosis and treatment of ACS of the thigh is vital to avoid irreversible tissue damage.57 58 This is particularly important for competitive athletes. Classical indications of ACS include the ‘6P’s’ of Pallor, Paresis, Paresthesia, diminished Pulse, increased compartment Pressure and Pain out of proportion with injury. Compartment pressure measurements are useful to clinch the diagnosis of ACS of the thigh59 and can help avoid missing the diagnosis.60 However, the precise threshold pressures that are diagnostic and indicate intervention remain unclear. Basal intramuscular pressure is 0–8 mm Hg,6 while pain and paresthesia occur at 20–30 mm Hg.61 Early work suggested that absolute compartment pressures ranging from 30 to 50 mm Hg are diagnostic of ACS and indicative of intervention.4 48 61–68 However, much of this early work was performed in the lower leg and forearm. The thigh compartments are anatomically distinct and the applicability of these threshold values to ACS of the thigh is uncertain. Pain out of proportion with injury is a common clinical indicator used in the general diagnosis of ACS.69 While pain has been reported as a reliable indicator of ACS of the thigh in some circumstances,57 62 70 71 the pain may be less prominent because the femoral nerve is not entirely enclosed within the anterior compartment.41 Diminished pain can also be the result of underlying nerve damage.66 72 Thigh contusions are common in contact sport, and differentiating between a mild contusion and ACS of the thigh can be difficult. Unlike other parts of the body, ACS of the thigh is rarely associated with fracture,47 and has not been reported in the sporting context.6 38 39 41 43 44 46 54 56 In the absence of obvious trauma and extreme pain, diagnosis of ACS of the thigh can easily be missed at an early stage. The rarity of ACS of the thigh makes it difficult to study and the most appropriate treatment for this disorder is not clear. A prompt fasciotomy with concurrent evacuation of haematoma is Smith RDJ, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210856
Rare disease frequently advocated to restore normal capillary perfusion.41 57 73 Poor outcomes have been associated with delayed surgical intervention57 74 and a systematic review by Hayakawa et al58 reported that delayed fasciotomy was associated with higher rates of amputation and death. Of the sporting cases reported, 10 of 16 cases underwent fasciotomy after presenting with absolute compartment pressures ranging from 39 to 120 mm Hg.38 39 41 43 46 54 56 No surgical complications were reported and 4 of 10 cases returned to their respective sports.38 39 41 43 46 54 56 It is noteworthy that 5 of 16 athletes in the reported cases continued to play after sustaining the injury,41 54 which may have exacerbated the injury and narrowed the window for early intervention. Several studies have also reported successful conservative treatment of athletes with ACS of the thigh with compartment pressures greater than 45 mm Hg.6 44 The authors of these studies noted that fasciotomies can increase morbidity and are unnecessary in some circumstances.6 44 Indeed, postoperative adhesions can limit joint flexion and high rates of infection after fasciotomies have been reported.55 However, the risk of infection in young athletes is relatively low,38 41 43 46 54 56 while complications associated with delayed fasciotomy are grave.57 58 74 Conservative treatment may be appropriate in some instances, but fasciotomy remains the preferred treatment in cases of full blown ACS of the thigh.43 Our case demonstrates that fasciotomy can be performed without complication and that in combination with good rehabilitation, a competitive athlete can return to full sporting participation at preinjury standard. The rare and insidious nature of ACS of the thigh in athletes means that a diagnosis can easily be missed. An awareness of risk factors associated with this condition might help in early recognition and treatment. Of the sporting reports that noted sex, 100% were male with mean age of 22.8 years.6 38 39 41 43 46 54 56 The propensity for young, muscular, athletic males to develop ACS has been noted in the literature4 40 70 and reflects our presented case. McQueen et al4 suggests that young men may have larger muscle volumes relative to a fixed compartment size, which reduces the amount of free space available for swelling after injury. A large muscle mass combined with an increased risk of trauma appear to be significant risk factors for ACS of the thigh in a sporting context. Many questions remain regarding the optimal threshold diagnostic indications and most appropriate treatments for ACS of the thigh. A high index of suspicion must be maintained particularly when treating young, muscular male athletes. Early diagnosis and prompt treatment is vital to avoid deleterious consequences that can end not only careers, but also lives.
Learning points
to edit and review the paper. SK treated the patient after injury and conceived the idea of submitting the case report. Along with HR-M, SK gathered the images for the case. He also helped to write and revise the paper. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3 4 5
6 7 8 9 10 11 12
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14 15 16
17 18 19 20
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▸ Acute compartment syndrome of the thigh may be difficult to diagnose in the sporting context and symptoms may develop insidiously. ▸ A high index of suspicion must be maintained for thigh contusions in the absence of fracture, particularly for muscular, young, male athletes. ▸ With prompt fasciotomy and thorough rehabilitation, it is possible for a competitive athlete to regain preinjury level of competition without long-term sequela.
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Contributors RDJS performed the literature review and wrote the paper with SK. HR-M was involved with the treatment and rehabilitation of the patient, and helped Smith RDJ, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210856
Sheridan GW, Matsen F III. Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am 1976;58:112–15. Vollmar B, Westermann S, Menger MD. Microvascular response to compartment syndrome-like external pressure elevation: an in vivo fluorescence microscopic study in the hamster striated muscle. J Trauma 1999;46:91–6. Mars M, Hadley GP. Raised intracompartmental pressure and compartment syndromes. Injury 1998;29:403–11. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br 2000;82:200–3. Burghardt RD, Siebenlist S, Döbele S, et al. Compartment syndrome of the thigh. A case report with delayed onset after stable pelvic ring fracture and chronic anticoagulation therapie. BMC Geriatr 2010;10:51. Riede U, Schmid M, Romero J. Conservative treatment of an acute compartment syndrome of the thigh. Arch Orthop Trauma Surg 2007;127:269–75. Burns B, Sproule J, Smyth H. Acute compartment syndrome of the anterior thigh following quadriceps strain in a footballer. Br J Sports Med 2004;38:218–20. King TW, Lerman OZ, Carter JJ, et al. Exertional compartment syndrome of the thigh: a rare diagnosis and literature review. J Emerg Med 2010;39:e93–9. Bidwell J, Gibbons C, Godsiff S. Acute compartment syndrome of the thigh after weight training. Br J Sports Med 1996;30:264–5. Nau T, Menth-Chiari WA, Seitz H, et al. Acute compartment syndrome of the thigh associated with exercise. Am J Sports Med 2000;28:120–2. Kahan JS, McClellan RT, Burton DS. Acute bilateral compartment syndrome of the thigh induced by exercise. A case report. J Bone Joint Surg Am 1994(7):1068–71. Wise JJ, Fortin PT. Bilateral, exercise-induced thigh compartment syndrome diagnosed as exertional rhabdomyolysis a case report and review of the literature. Am J Sports Med. 1997;25:126–9. Kuklo TR, Tis JE, Moores LK, et al. Fatal rhabdomyolysis with bilateral gluteal, thigh, and leg compartment syndrome after the Army Physical Fitness Test. A case report. Am J Sports Med. 2000;28:112–16. Presnal BP, Heavilon JA. Exercise-induced acute compartment syndrome of the thigh. Case report. Am J Knee Surg 1994;8:77–9. Bertoldo U, Nicodemo A, Pallavicini J, et al. Acute bilateral compartment syndrome of the thigh induced by spinning training. Injury 2003;34:791–2. Rahm M, Probe R. Extensive deep venous thrombosis resulting in compartment syndrome of the thigh and leg. A case report. J Bone Joint Surg Am 1994;76:1854–7. Westrich GH, Toledano B. Compartment syndrome in the leg requiring fasciotomy after bicillin injection in the thigh. Orthopedics 1995;18:1113–14. Swan MC, Lam D, Giele HP. Intravascular ecstasy: an unusual cause of thigh compartment syndrome. J Trauma 2006;60:1129–31. Cawrse N, Palmer J, Hayes C, et al. A snake in the clinical grass: late compartment syndrome in a child bitten by an adder. Br J Plast Surg 2002;55:434–5. Ebraheim NA, Hoeflinger MJ, Savolaine ER, et al. Anterior compartment syndrome of the thigh as a complication of blunt trauma in a patient on prolonged anticoagulation therapy. Clin Orthop Relat Res 1991;263:180–4. Kakkar R, Ellis M, Fearon PV. Compartment syndrome of the thigh as a complication of anticoagulant therapy in a patient with a left ventricular assist device (Berlin Heart). Gen Thorac Cardiovasc Surg 2010;58:477–9. Limberg RM, Dougherty C, Mallon WK. Enoxaparin-induced bleeding resulting in compartment syndrome of the thigh: a case report. J Emerg Med 2011;41:e1–4. Gates JD, Bichell DP, Rizzo RJ, et al. Thigh ischemia complicating femoral vessel cannulation for cardiopulmonary bypass. Ann Thorac Surg 1996;61:730–3. Karkos CD, Hughes R, Prasad V, et al. Thigh compartment syndrome as a result of a false aneurysm of the profunda femoris artery complicating fixation of an intertrochanteric fracture. J Trauma 1999;47:393–5. Asplund MW. Acute thigh compartment syndrome post femoral vein catheterization: a case report. WMJ 2008;107:244–6. Seybold EA, Busconi BD. Anterior thigh compartment syndrome following prolonged tourniquet application and lateral positioning. Am J Orthop (Belle Mead NJ) 1996;25:493–6. Kunkel JM. Thigh and leg compartment syndrome in the absence of lower extremity trauma following MAST application. Am J Emerg Med. 1987;5:118–20. Mallik K, Diduch DR. Acute noncontact compartment syndrome. J Orthop Trauma. 2000;14:509–10. Bass RR, Allison EJ JR, Reines HD, et al. Thigh compartment syndrome without lower extremity trauma following application of pneumatic antishock trousers. Ann Emerg Med. 1983;12:382–4.
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Sancineto C, Godoy Monzon D. Compartment syndrome of the thigh: an unusual complication after spinal surgery. J Spinal Disord Tech. 2004;17:336–8. Mai DD, MacDonald SJ, Bourne RB. Compartment syndrome of the right anterior thigh after primary total hip arthroplasty. Can J Surg. 2000;43:226–7. Tani Y, Inoue K, Hukuda S. Acute compartment syndrome in the thigh after revision hip arthroplasty: a case report. Acta Orthop. 1996;67:71–2. Price C, Ribeiro J, Kinnebrew T. Compartment syndromes associated with postoperative epidural analgesia. A case report. J Bone Joint Surg Am 1996;78:597–9. Nadeem RD, Clift BA, Martindale JP, et al. Acute compartment syndrome of the thigh after joint replacement with anticoagulation. J Bone Joint Surg Br 1998;80:866–8. Blasier RB, Pape JM. Simulation of compartment syndrome by rupture of the deep femoral artery from blunt trauma. Clin Orthop Relat Res 1991;266:214–17. Viegas SF, Rimoldi R, Scarborough M, et al. Acute compartment syndrome in the thigh: a case report and a review of the literature. Clin Orthop Relat Res 1988;234:232–4. Mülder K, Sakoman V, Kecskes S, et al. [Compartment syndrome after femoral contusion. Case report and review of the literature]. Aktuelle Traumatol 1991;21:139–42. Colosimo AJ, Ireland ML. Thigh compartment syndrome in a football athlete: a case report and review of the literature. Med Sci Sports Exerc 1992;24:958–63. Winternitz WA, Metheny JA, Wear LC. Acute compartment syndrome of the thigh in sports-related injuries not associated with femoral fractures. Am J Sports Med 1992;20:476–8. Gorman PW, McAndrew MP. Acute anterior compartmental syndrome of the thigh following contusion. A case report and review of the literature. J Orthop Trauma 1987;1:68–70. Rööser B, Bengtson S, Hägglund G. Acute compartment syndrome from anterior thigh muscle contusion: a report of eight cases. J Orthop Trauma 1991;5:57–9. Lindsay MB. Quadriceps compartment syndrome from minor trauma. Acad Emerg Med 1999;6:860–1. Machold W, Muellner T, Kwasny O. Is the return to high-level athletics possible after fasciotomy for a compartment syndrome of the thigh? A case report. Am J Sports Med 2000;28:407–10. Robinson D, On E, Halperin N. Anterior compartment syndrome of the thigh in athletes-indications for conservative treatment. J Trauma 1992;32:183–6. Klasson S, Vander Schilden JL. Acute anterior thigh compartment syndrome complicating quadriceps hematoma. Two case reports and review of the literature. Orthop Rev 1990;19:421–7. Lee AT, Fanton GS, McAdams TR. Acute compartment syndrome of the thigh in a football athlete: a case report and the role of the vacuum-assisted wound closure dressing. J Orthop Trauma 2005;19:748–50. Hope MJ, McQueen MM. Acute compartment syndrome in the absence of fracture. J Orthop Trauma 2004;18:220–4. Allen M, Stirling A, Crawshaw C, et al. Intracompartmental pressure monitoring of leg injuries. An aid to management. J Bone Joint Surg Br 1985;67:53–7. Foster RD, Albright JA. Acute compartment syndrome of the thigh: case report. J Trauma 1990;30:108–10. Gillooly JJ, Hacker A, Patel V. Compartment syndrome as a complication of a stab wound to the thigh: a case report and review of the literature. Emerg Med J 2007;24:780–1.
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Mithöfer K, Lhowe DW, Altman GT. Delayed presentation of acute compartment syndrome after contusion of the thigh. J Orthop Trauma 2002;16:436–8. Tarlow SD, Achterman CA, Hayhurst J, et al. Acute compartment syndrome in the thigh complicating fracture of the femur. A report of three cases. J Bone Joint Surg Am 1986;68:1439–43. Suzuki T, Moirmura N, Kawai K, et al. Arterial injury associated with acute compartment syndrome of the thigh following blunt trauma. Injury 2005;36:151–9. An HS, Simpson JM, Gale S, et al. Acute anterior compartment syndrome in the thigh: a case report and review of the literature. J Orthop Trauma 1987;1:180–2. Schwartz JT Jr, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am 1989;71:392–400 (0021–9355 (Print)). Langen RP, Ruggieri R. Acute compartment syndrome in the thigh complicated by a pseudoaneurysm. A case report. J Bone Joint Surg Am 1989;71:762–3. Mithoefer K, Lhowe DW, Vrahas MS, et al. Functional outcome after acute compartment syndrome of the thigh. J Bone Joint Surg Am 2006;88:729–37. Hayakawa H, Aldington DJ, Moore RA. Acute traumatic compartment syndrome: a systematic review of results of fasciotomy. Trauma 2009;11:5–35. McCaffrey DD, Clarke J, Bunn J, et al. Acute compartment syndrome of the anterior thigh in the absence of fracture secondary to sporting trauma. J Trauma 2009;66:1238–42. Tiwari A, Haq A, Myint F, et al. Acute compartment syndromes. Br J Surg 2002;89:397–412. 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 Am 1978;60:1091–5. Mubarak SJ, Hargens AR. Compartment syndromes and Volkmann’s contracture. WB Saunders Company, 1981. Blick S, Brumback R, Poka A, et al. Compartment syndrome in open tibial fractures. J Bone Joint Surg Am 1986;68:1348–53. Gelberman RH, Szabo RM, Williamson RV, et al. Tissue pressure threshold for peripheral nerve viability. Clin Orthop Relat Res 1983;178:285–91. Matsen FA III, Winquist RA, Krugmire RB Jr. Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am 1980;62:286–91. Whitesides TE Jr, Haney TC, Morimoto K, et al. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res 1975;113:43–51. Halpern AA, Greene R, Nichols T, et al. Compartment syndrome of the interosseous muscles: early recognition and treatment. Clin Orthop Relat Res 1979;140:23–5. Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint Surg Br 1984;66:93–7. Whitesides TE, Heckman MM. Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg 1996;4:209–18. Badhe S, Baiju D, Elliot R, et al. The ‘silent’compartment syndrome. Injury 2009;40:220–2. Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003;85:625–32. Wright JG, Bogoch ER, Hastings DE. The ‘occult’ compartment syndrome. J Trauma 1989;29:133–4. Hutchinson MR, Ireland ML. Common compartment syndromes in athletes. Sports Med 1994;17:200–8. Kanlic EM, Pinski SE, Verwiebe EG, et al. Acute morbidity and complications of thigh compartment syndrome: a report of 26 cases. Patient Saf Surg 2010;4:13.
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Smith RDJ, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210856
CASE REPORT
Acute compartment syndrome of the thigh in a rugby player Richard David James Smith,1 Holly Rust-March,2 Stefan Kluzek1 1
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK 2 Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK Correspondence to Richard David James Smith, [email protected] Accepted 20 July 2015
SUMMARY In the absence of obvious trauma, diagnosis of acute compartment syndrome (ACS) of the thigh can easily be delayed, as disproportional pain is not always present. We present a case of ACS of the anterior right thigh compartment in a healthy, semiprofessional rugby player with normal coagulation, who sustained a seemingly innocuous blow during a rugby match. Following early surgical fasciotomy, he returned to his preinjury playing standards within 12 months. Our literature review suggests that high muscle mass, young, athletic males participating in a contact sport are mostly at risk of developing ACS of the thigh.
BACKGROUND
To cite: Smith RDJ, RustMarch H, Kluzek S. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015210856
Acute compartment syndrome (ACS) is a medical emergency that can lead to amputation and death.1 ACS is commonly caused by a trauma that damages the muscles and vasculature within an osseofascial compartment and leads to oedema and swelling. The unyielding fascia surrounding the compartment limits this expansion, which increases intracompartmental pressure and reduces the blood supply to the nerves and muscles within. If this pressure exceeds normal capillary perfusion pressure, reduced blood flow can cause ischaemia and tissue necrosis.2 3 ACS is commonly associated with compartments of the lower leg and forearm,4 while ACS of the thigh is relatively rare.4 5 This may be because the thigh compartments are large and encapsulated with dilative fascia,6 and therefore can readily accommodate expansion. Thigh compartments also blend anatomically with the hip,7 which can provide additional space into which the accumulating fluid may be discharged. ACS of the thigh occurs most frequently in the anterior compartment8 due to vulnerability of this site to injury. The aetiology of ACS of the thigh is diverse. Cases of ACS of the thigh have been reported as a result of exercise,7 9–15 deep vein thrombosis,16 drug toxicity,17 18 venomous snake bite,19 anticoagulation therapy,20–22 vascular injury,23–25 continuous external compression,26 use of antishock trousers,27–29 surgical complications30–34 and trauma, both with and without fracture.35–55 Traumatic ACS of the thigh in sport has been reported in football,6 41 44 handball,41 44 American football,38 46 lacrosse,39 softball,54 karate,56 kickboxing43 and in one case of a rugby player.41 This is a rare condition in sport with limited epidemiological data. There is little consensus in the field regarding the precise diagnostic criteria and the
most appropriate treatment technique. Furthermore, little has been done to raise awareness of the risk factors associated with ACS of the thigh in sport.
CASE PRESENTATION Presenting features We present a case of a fit and healthy 37-year-old man who developed ACS of the thigh after sustaining a seemingly innocuous blow to the right anterior lower thigh during a rugby match. The only notable symptom was mild thigh swelling and immediate ache. After initially reporting mild tenderness, his pain gradually developed 1 h after sustaining the injury and he was admitted to the local emergency department 3 h postinjury.
Medical/social/family history The patient had a multiligament surgical reconstruction on his left knee 5 years prior to this presentation. The patient has also had hypertension for the last 4 years, which has been successfully managed pharmacologically. The patient had not sustained any previous injury to his right knee.
INVESTIGATIONS Following admission, the circumference of each thigh was measured. The circumference of the patient’s right mid-thigh was 6 cm larger than his left, and was comparatively more painful and tender. The pressure reading of the right anterior thigh compartment was 38 mm Hg.
TREATMENT A diagnosis of ACS of the right anterior thigh was made and a fasciotomy of the anterior compartment was performed 3 h after admission to the emergency department (figure 1). Following fasciotomy, pressure in the anterior thigh compartment dropped from 38 mm Hg to 17 mm Hg. The patient received a skin graft 8 days following the fasciotomy to cover the large residual wound (figure 2).
OUTCOME AND FOLLOW-UP With regular rehabilitation and physiotherapy supervised by the club physiotherapist, the patient recovered within 6 months. Unfortunately, due to the fasciotomy and skin grafting, the patient reported ongoing patella instability and this reduced the patient’s confidence to participate in rugby training. A reduction of the skin flap with mesh insertion was successfully performed 8 months after the injury to further support the joint. The patient was able to take part in full training 12 months after the injury (figure 3).
Smith RDJ, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210856
1
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Figure 1 Right anterior thigh immediately following fasciotomy on the day of injury.
Figure 3 Right anterior thigh 12-months postinjury (after reduction and skin flap insertion).
DISCUSSION ACS of the thigh is a rare diagnosis.4 It is most commonly associated with motor vehicle accidents,4 but has also been reported as a result of trauma in sport.6 38 39 41 43 44 46 54 56
Figure 2 Skin grafted wound 2-months postinjury. 2
Early diagnosis and treatment of ACS of the thigh is vital to avoid irreversible tissue damage.57 58 This is particularly important for competitive athletes. Classical indications of ACS include the ‘6P’s’ of Pallor, Paresis, Paresthesia, diminished Pulse, increased compartment Pressure and Pain out of proportion with injury. Compartment pressure measurements are useful to clinch the diagnosis of ACS of the thigh59 and can help avoid missing the diagnosis.60 However, the precise threshold pressures that are diagnostic and indicate intervention remain unclear. Basal intramuscular pressure is 0–8 mm Hg,6 while pain and paresthesia occur at 20–30 mm Hg.61 Early work suggested that absolute compartment pressures ranging from 30 to 50 mm Hg are diagnostic of ACS and indicative of intervention.4 48 61–68 However, much of this early work was performed in the lower leg and forearm. The thigh compartments are anatomically distinct and the applicability of these threshold values to ACS of the thigh is uncertain. Pain out of proportion with injury is a common clinical indicator used in the general diagnosis of ACS.69 While pain has been reported as a reliable indicator of ACS of the thigh in some circumstances,57 62 70 71 the pain may be less prominent because the femoral nerve is not entirely enclosed within the anterior compartment.41 Diminished pain can also be the result of underlying nerve damage.66 72 Thigh contusions are common in contact sport, and differentiating between a mild contusion and ACS of the thigh can be difficult. Unlike other parts of the body, ACS of the thigh is rarely associated with fracture,47 and has not been reported in the sporting context.6 38 39 41 43 44 46 54 56 In the absence of obvious trauma and extreme pain, diagnosis of ACS of the thigh can easily be missed at an early stage. The rarity of ACS of the thigh makes it difficult to study and the most appropriate treatment for this disorder is not clear. A prompt fasciotomy with concurrent evacuation of haematoma is Smith RDJ, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210856
Rare disease frequently advocated to restore normal capillary perfusion.41 57 73 Poor outcomes have been associated with delayed surgical intervention57 74 and a systematic review by Hayakawa et al58 reported that delayed fasciotomy was associated with higher rates of amputation and death. Of the sporting cases reported, 10 of 16 cases underwent fasciotomy after presenting with absolute compartment pressures ranging from 39 to 120 mm Hg.38 39 41 43 46 54 56 No surgical complications were reported and 4 of 10 cases returned to their respective sports.38 39 41 43 46 54 56 It is noteworthy that 5 of 16 athletes in the reported cases continued to play after sustaining the injury,41 54 which may have exacerbated the injury and narrowed the window for early intervention. Several studies have also reported successful conservative treatment of athletes with ACS of the thigh with compartment pressures greater than 45 mm Hg.6 44 The authors of these studies noted that fasciotomies can increase morbidity and are unnecessary in some circumstances.6 44 Indeed, postoperative adhesions can limit joint flexion and high rates of infection after fasciotomies have been reported.55 However, the risk of infection in young athletes is relatively low,38 41 43 46 54 56 while complications associated with delayed fasciotomy are grave.57 58 74 Conservative treatment may be appropriate in some instances, but fasciotomy remains the preferred treatment in cases of full blown ACS of the thigh.43 Our case demonstrates that fasciotomy can be performed without complication and that in combination with good rehabilitation, a competitive athlete can return to full sporting participation at preinjury standard. The rare and insidious nature of ACS of the thigh in athletes means that a diagnosis can easily be missed. An awareness of risk factors associated with this condition might help in early recognition and treatment. Of the sporting reports that noted sex, 100% were male with mean age of 22.8 years.6 38 39 41 43 46 54 56 The propensity for young, muscular, athletic males to develop ACS has been noted in the literature4 40 70 and reflects our presented case. McQueen et al4 suggests that young men may have larger muscle volumes relative to a fixed compartment size, which reduces the amount of free space available for swelling after injury. A large muscle mass combined with an increased risk of trauma appear to be significant risk factors for ACS of the thigh in a sporting context. Many questions remain regarding the optimal threshold diagnostic indications and most appropriate treatments for ACS of the thigh. A high index of suspicion must be maintained particularly when treating young, muscular male athletes. Early diagnosis and prompt treatment is vital to avoid deleterious consequences that can end not only careers, but also lives.
Learning points
to edit and review the paper. SK treated the patient after injury and conceived the idea of submitting the case report. Along with HR-M, SK gathered the images for the case. He also helped to write and revise the paper. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
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6 7 8 9 10 11 12
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14 15 16
17 18 19 20
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▸ Acute compartment syndrome of the thigh may be difficult to diagnose in the sporting context and symptoms may develop insidiously. ▸ A high index of suspicion must be maintained for thigh contusions in the absence of fracture, particularly for muscular, young, male athletes. ▸ With prompt fasciotomy and thorough rehabilitation, it is possible for a competitive athlete to regain preinjury level of competition without long-term sequela.
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Contributors RDJS performed the literature review and wrote the paper with SK. HR-M was involved with the treatment and rehabilitation of the patient, and helped Smith RDJ, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210856
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Smith RDJ, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-210856
