Arch Orthop Trauma Surg (1992) 111:314-317

ArcbwofOrthopaedic

..dTraumaSurgery © Springer-Verlag1992

The pelvic compartment syndrome U. Bosch and H. Tscherne

Department of Trauma Surgery, Hannover Medical School, Konstanty-Gutschow-Strasse8, W-3000 Hannover 61, Federal Republic of Germany

Summary. In the pelvic region three major compartments (gluteus medius-minimus compartment, gluteus maximus compartment, and iliopsoas compartment) can be distinguished from the smaller compartment of the tensor fasciae latae muscle. Pelvic compartment syndromes are rare. A clear history of trauma is often lacking. Association with drug and alcohol abuse is common, as is the association with the widespread use of anticoagulant therapy. From 1982 to 1990 six patients with acute buttock compartment syndrome were treated in the Department of Trauma Surgery of Hannover Medical School. In five patients fasciotomy of the gluteal compartment was performed. Two patients with a compartment syndrome secondary to necrotizing fasciitis died of septic multiple organ failure. The mean follow-up of the four other patients was 29 months (7-48 months). Three of these four patients revealed a decrease of gluteal muscle volume. Ergometric tests showed a decrease in gluteal muscle force in all patients.

The compartment syndrome of the gluteal region is rarely mentioned in the literature, with only a few case reports published (Table 1) [4, 7, 8, 12-15]. In his war memoirs Larrey [9], the surgeon general of Napoleon's army, described ischemic muscle necrosis in the gluteal region of soldiers who died during the Berlin siege in 1806 of carbon monoxide poisoning. The history of such patients is frequently lacking in a relevant trauma. Several authors describe compartment syndrome of the gluteal region related to prolonged pressure after alcohol and drug abuse [4, 12, 15]. Paralysis of the quadriceps muscle following a compartment syndrome of the ilipsoas musculature is more frequently observed. The cause of femoral nerve compression at this location is usually spontaneous retroperitoneal hemorrhage in hemophiliacs or over-anticoagulation treatment [1, 2, 5, 11, 17]. Hemorrhage also occurs after hyperextension of the trunk and hip [6], The significance of the pelvic compartment syndrome resides on the one hand in the compression-induced, ischemic damage to nerves such as the sciatic nerve, the Correspondence to: U. Bosch

femoral nerve, and, less frequently, the obturator nerve, and on the other hand in the possible systemic effects of a crush syndrome due to ischemia of a large muscle mass [12, 14, 16].

Anatomy

The pelvis can essentially be divided into the iliopsoas muscle compartment, the gluteus medius and minimus compartment, and the gluteus maximus compartment. Anterolaterally lies the separate tensor fasciae latae compartment. The gluteus medius and minimus lie within an osteofibrous sheath consisting of the iliac bone on one side and the tough gluteal fascia on the other. This fascia splits into two layers which enclose the gluteus maximus posteriorly and the tensor fasciae latae anteriorly. The gluteal fascia over the gluteus maximus is thin and blends with the epimysium, entering the muscle between fiber bundles to form intramuscular septa. The short external rotator muscles of the hip joint can be responsible for posttraumatic, compression-induced damage to the sciatic nerve due to their anatomical proximity. The symptoms of ischemic damage to the sciatic nerve, which leaves the small pelvis beneath the lower border of the piriformis, are prominent among neuromuscular problems associated with compartment syndromes of the gluteal region [14]. Function of the gluteal nerves and the posterior femoral cutaneous nerve can also be reduced. Branches of the latter, the n. clunium inferiores, innervate large areas of gluteal skin.

Table 1. The pelvic compartmentsyndromein the gluteal region: literature review

Author

Year

n

Kaufmanand Choi Klock and Sexton Evanski and Waugh Owen et al. Echtermeyer Petrick et al. Neal et al.

1972 1973 1977 1978 1985 1988 1989

1 1 1 3 3 1 3

315 Case histories Case 1. K.-H.S., 51 years old This patient was a steel worker who was pinned with his pelvis caught between two steel beams for 20 min during bridge construction. A pelvic contusion with fracture of the right posterior inferior iliac spine and a 3 cm × 7 cm soft tissue contusion proximally and laterally, with moderate swelling and tenderness at the first examination, were diagnosed. Peripheral perfusion and sensory and motor functions were intact in the right leg. Latter, a major hematoma formed in the right gluteal region. After a short period of bed rest and cryotherapy, mobilization on crutches started.

Fig. 1. Course of femoral nerve in the iliopsoas muscle compartment

T h e iliac a n d psoas muscles also lie w i t h i n a n osteofibrous sheath consisting of iliac b o n e a n d iliac fascia. T h e f e m o r a l n e r v e arises b e t w e e n the fibers of the psoas m a j o r muscle o u t of the l u m b a r plexus ( L I I - I V ) a n d r u n s d i a g o n a l l y t h r o u g h the muscle to the lateral b o r d e r of the psoas muscle (Fig. 1). F r o m t h e r e it r u n s b e t w e e n the psoas a n d iliac muscles, c o v e r e d b y the iliac fascia, to the l a c u n a m u s c u l o r u m a n d t h e n to the v e n t r a l surface of the thigh. B e t w e e n the muscles a good b l o o d supply to the f e m o r a l n e r v e is lacking [17]. Ischemic d a m a g e to this nerve during a c o m p a r t m e n t s y n d r o m e of the iliopsoas muscle can lead to paralysis of the q u a d r i c e p s femoris muscle a n d loss of s e n s o r y f u n c t i o n in the distal, a n t e r i o r thigh as well as the a n t e r i o r a n d m e d i a l areas of the lower leg. T h e m e d i a l b o r d e r of the foot ( s a p h e n u s n e r v e ) can also b e affected. T h e o b t u r a t o r n e r v e also arises in the L I I - I V s e g m e n t s of the l u m b a r plexus, b u t follows the m e d i a l edge of the psoas muscle, w h e r e it p e n e t r a t e s the fascia a n d leaves the c o m p a r t m e n t .

Case 2. W.B., 35 years old This patient was a railway worker who fell 1.5m with a cement platform and was partially buried under it. Initial primary care was given at a local hospital, but on the day of the accident the patient was transferred to MHH because of continuous internal blood loss. On admission the patient was somnolent, hemoglobin value was 7.8 g% after administration of seven erythrocyte concentrates, and a nondislocated anterior pelvic ring fracture as well as a soft tissue contusion of the right gluteal region was diagnosed. The massive hematoma of the right gluteal region extended m mid thigh and through the perineum to the scrotal area. Perfusion and sensory and motor functions of the right leg were intact. The subfascial tissue pressure in the right gluteal muscles was approximately 35mmHg. Fasciotomy, removal of necrotic muscle tissue and a large hematoma, and ligation of a large branch of the inferior gluteal artery were carried out 11.5 h after the traumatic incident. After 10 days ambulation was begun. Case 3. H.B., 52 years old After an aortic valve replacement and an aortocoronary bypass this patient received anticoagulant therapy for years (Marcumar). He slipped on ice and fell on his right gluteal region. After initial 1-week treatment as an outpatient he was referred to the MHH because of considerable tension, swelling, and pain in the right gluteal region. A curved incision as in the posterior approach to the hip was used to split the right gluteal fascia. A hematoma the size of an orange was found in the gluteus maximus. A second hematoma was located over the short rotator muscles of the hip joint. Case 4. J.S., 23 years old This patient was admitted to intensive care unconscious after consuming barbiturates and oxazepam. The next day revealed a paresis of the left leg after the patient regained consciousness. The left thigh including the left gluteal region showed increasing swelling and tension blisters with a subfascial pressure of 32-39mmHg. Decompression of the gluteal and thigh muscles was accomplished through a single incision. Severe muscle edema was found as well as a hematoma in the short rotators which impinged on the sciatic nerve. After 10 days complete paralysis of the sciatic nerve was still to be observed, while femoral nerve function was within normal limits.

Patients and methods From 1982 to 1990 the Department of Trauma Surgery of the Hannover Medical School (MHH) treated six patients (male : female = 5:1; median age 41.5 years, range 16-52 years) with an acute gluteal compartment syndrome. In three cases the compartment syndrome was the result of trauma (pelvic contusion without serious fractures), in two cases the syndrome arose in the course of a phlegmonic infection (necrotizing fasciitis), and in one case druginduced unconsciousness resulted in a compartment syndrome based on a pressure injury. In five patients fasciotomy was performed, while one patient was treated conservatively. The two patients with phlegmonic infections died in septic multiple organ failure. A compartment syndrome of the iliopsoas muscle compartment was not observed during the above period of time.

Case 5. D.W., 48 years old After surgical repair of a closed patella fracture with soft tissue injury, a massive compartment syndrome of the operated leg with participation of the left pelvis developed 5 days after operation. Necrotizing fasciitis was diagnosed, and after initial fasciotomy in both the upper and lower leg, open exarticulation at the hip joint was carried out the same day. The patient died of septic multiple organ failure. Case 6. S.M., 16 years old After admission to a local hospital with gluteal phlegmonic infection and sepsis, this patient was transferred to MHH 2 days latter. A fasciotomy of the right gluteal and thigh regions was performed after clinicalpresentation of a compartment syndrome, with re-

316 Table 2. Results of follow-up examination. PR, Patellar reflex; ATR, Achilles tendon reflex

Case

Subjective state of health

Gluteal skin condition

Muscle atrophy

Hyp- and dysesthesias

1

Not reduced

Striated skin depression over right gluteal muscle

Right gluteal muscles

2

Intermittent pain in the right gluteal region. Rapid fatigue in these muscles

Curved, livid scar, dehiscent to 1 cm

3

Weather-dependent pain in the right gluteal area

4

Reduced due to partial loss of left sciatic nerve function

Reflexes

Standing on toes

Standing on heels

PR

ATR

N. clunium inferiores on the right side

+

+

Possible

Possible

Right gluteal muscles without adequate tone

N. clunium inferiores on the right side

+

+

Possible

Possible

Healed scar

None

None

+

-

Difficult on the right side

Possible

Healed scar

Left gluteal thigh and lower leg muscles

N. cutaneous femoris lateralis on the left side

Reduced on the left side

-

Difficult on the left side

Not possible on the left side

moval of copious muscle and fascial necrosis. This patient finally died in septic multiple organ failure. Four of the six patients (cases 1-4) were examined 7-48 months (mean 29 months) after treatment for acute compartment syndrome. Following a thorough history taking, a clinical examination with an evaluation of muscle strength was performed according to the guidelines of the British Medical Research Council. Hip extensors, flexors, adductors, and abductors as well as foot extensors and flexors were evaluated. Hip muscle strength on both sides was also measured in the above muscle groups using an ergometric test. The patients extended, flexed, adducted, and abducted maximally in the hip joint while the foot of the moving leg was connected to a mechanical strength measurement device. Patient J.S. (case 4) was unable to perform the ergometric test. Based on ten measurements the mean value of muscle strength of each muscle group was calculated from plotted curves. The mean reduction of muscle strength was calculated as X1-X2/X1 • 100% ; X1 represents the mean value of strength measurements of the control side, X2 that of the affected side after compartment syndrome.

Statistics Statistical evaluation of muscle strength measurements on both sides were carried out using the F and t tests. The mean values of corresponding muscle groups were compared to find significant differences. The significance level was set at P < 0.05.

Table 3. Clinical evaluation of muscle strength (according to the British Medical Research Council)

Case

Hip flexor R/L

Hip extensor R/L

Hip abduc, R/L

Hip adduc, R/L

Foot Foot extensor flexor R/L R/L

1 2 3 4

5/5 4/5 5/5 5/5

5/5 3-4/5 5/5 5/5

5/5 4/5 5/5 5/5

5/5 5/5 5/5 5/5

5/5 5/5 5/5 5/2

5/5 5/5 4/5 5/4

R, Right; L, Left

Table 4. Mean relative muscle strength reduction in hip after compartment syndrome

Case

Extension

Abduction

Adduction

Flexion

[%]

[%]

[%]

[%1

40 46 10b

None a 27 15

14 38 26

2b 42 21

1 2 3

a Strength increase of 39% on the compartment syndrome side b Not significant

Results

At the time of follow-up examination, three patients s u b j e c t i v e l y felt t h e m s e l v e s to b e in a r e d u c e d s t a t e of h e a l t h . M a i n l y light, i n t e r m i t t e n t p a i n in t h e g l u t e a l reg i o n was given as t h e r e a s o n . O n l y t h e p a t i e n t w h o h a d b e e n in d r u g - i n d u c e d c o m a h a d gait a n o m a l i e s b e c a u s e o f r e m a i n i n g p a r e s i s o f t h e sciatic n e r v e . T h r e e o f f o u r p a t i e n t s s h o w e d s o m e a t r o p h y o f g l u t e a l muscles. A l l p a tients h a d a n e g a t i v e T r e n d e l e n b u r g sign. H y p - a n d dyse s t h e s i a s w e r e also r e c o r d e d in t h r e e o f f o u r p a t i e n t s in t h e g l u t e a l skin. T h e r a n g e o f m o t i o n of t h e h i p j o i n t was n o t o r o n l y slightly r e d u c e d in all cases. T h e p r e v i o u s l y e m p l o y e d p a t i e n t s w e r e a b t e to r e s u m e t h e i r e m p l o y m e n t (cases 1 a n d 2) ( T a b l e 2).

T a b l e 3 shows the results of the clinical muscle strength e v a l u a t i o n s . T a b l e 4 shows t h e r e l a t i v e r e d u c t i o n in m u s cle s t r e n g t h a f t e r c o m p a r t m e n t s y n d r o m e using e r g o m e t ric tests.

Discussion

A s d e s c r i b e d in t h e l i t e r a t u r e , t h e c o m p a r t m e n t synd r o m e o f t h e pelvis is a r a r e o c c u r r e n c e in this s t u d y as well. H o w e v e r , a n y a c u t e , p o s t t r a u m a t i c n e u r o m u s c u lar s y m p t o m s in t h e sciatic a n d f e m o r a l n e r v e r e g i o n s s h o u l d raise t h e p o s s i b i l i t y o f a c o m p a r t m e n t s y n d r o m e as a d i f f e r e n t i a l diagnosis. P a t i e n t s with d r u g - i n d u c e d

317 coma or anticoagulant therapy represent a high-risk group with regard to pelvic compartment syndrome. Phlegmonic infections in the thigh spreading to the pelvis, and gluteal phlegmones also carry an inherent risk of a compartment syndrome. Aside from general, clinical symptoms such as burning and boring pain, muscle weakness, tenderness, and swelling of the involved muscles, the subfascial measurement of tissue pressures is the most important aid in the diagnosis of a compartment syndrome of the gluteal region [3, 10], To demonstrate an iliopsoas compartment syndrome, ultrasonography of the flank and computed tomography of the pelvis are helpful. Diffuse muscle swelling (edema) and/or subfascial hematomas confirm the diagnosis. The incision is made slightly distal and parallel to the iliac crest, or, alternately, like a posterior approach to the hip joint. Here, the incision lies at the anterior edge of the gluteus maximus and runs distally to the greater trochanter. Due to its anatomy, the decompression of this muscle requires both fasciotomy and incisions comparable to an epimysiotomy [13, 14]. However, in the gluteal compartment syndrome, the decompression of the gluteus medius and minimus compartment is the decisive factor, due to their location in an osteofibrous sheath. When neurological symptoms indicate, revision of the sciatic nerve follows in the region of the short external rotators of the hip. The tensor fasciae latae must be separately decompressed. The approach to the iliopsoas muscle and femoral nerve for decompression and exploration can be made by an extraperitoneal approach through a symptomatic-sided flank incision [1]. In bilateral iliopsoas compartment syndromes a transperitoneal approach can be indicated. The most surprising result of the follow-up examination in this study was the absence of any functionally relevant gluteal insufficiency in spite of visible gluteal atrophy in two of three patients with posttraumatic compartment syndrome. However, muscle strength measurements using an ergometric test did show a significant reduction in muscle strength in all three cases. The absence of severe pelvic trauma as the cause of compartment syndrome (e.g. crush trauma) is also unexpected. This could be explained by the biomechanics of these injuries, Since fractures or fascia ruptures can often open compartments traumatically. The results of this study suggest that the treatment of manifest pelvic compartment syndromes must, as in the

extremities, consist of early and complete decompression by fasciotomy to prevent the risk of permanent nerve and muscle damage with resulting invalidity of the patient. Thus the surgical treatment regimen is given top priority. Only the hemophiliac patient might warrant more conservative treatment [5].

References

1. A1-Zamil A, Christenson JT (1988) Psoas muscle hematoma an acute compartment syndrome. VASA 17 : 141-143 2. Brantigan JW, Owens ML, Moody FG (1976) Femoral neuropathy complicating anticoagulant therapy. Am J Surg 132: 108-109 3. Echtermeyer V (1985) Das Kompartmentsyndrom. Diagnostik und Therapie. Hefte Unfallheilkd, vo1169. Springer, Berlin Heidelberg New York 4. Evanski PM, Waugh TR (1977) Gluteal compartment syndrome: case report. J Trauma 17:323-324 5. Goodfellow J, Fearn CB d'A, Matthews JM (1967) Iliacus haematoma syndrome. J Bone Joint Surg [Br] 49 : 748-756 6. Green JP (1972) Proximal avutsion of the iliacus with paralysis of the femoral nerve. J Bone Joint Surg [Br] 54 : 154-156 7. Kaufman G, Choi B (1972) Ischemic necrosis of muscles of the buttock. J Bone Joint Surg [Am] 54 : 1079-1082 8. Klock JC, Sexton MJ (1973) Rhabdomyolysis and acute myoglobinuric renal failure following heroin use. Calif Med 119:5-8 9. Larrey DJ (1812) Memories de chirurgie militaire et campagnes 3, 13. Smith and Buisson, Paris 10. Matsen III FA (1975) Compartmental syndrome. Clin Orthop 113 : 8-14 11. Mastrianni PP, Roberts MP (1983) Femoral neuropathy and retroperitoneal hemorrhage. Neurosurgery 13 : 44-47 12. Neal WC, Schmalzried TP, Eckardt JJ (1989) Diagnosis and treatment of buttock compartment syndromes. In: American Academy of Orthopaedic Surgeons (ed) 56th Annual Meeting of American Academy of Orthopaedic Surgeons, Las Vegas, February 9-14, 1989, p 130 13. Oestem HJ, Echtermeyer V (1984) Das Kompartment-Syndrom. Schriftenreihe: Unfalhnedizinische Tagungen der Landesverbgnde der gewerblichen Berufsgenossenschaften 53 : 169-192 14. Owen CA, Woody PR, Mubarak SJ, Hargens AR (1978) Gluteal compartment syndromes. Clin Orthop 132 : 57-60 15. Petrik ME, Stambough JL, Rothman RH (1988) Posttraumatic gluteal compartment syndrome. Clin Orthop 231 : 127-129 16. Szyszkowitz R, Reschauer R (1982) Atiologie, Pathophysiologie und Lokalisation des Kompartment-Syndroms. Unfallheilkd 85 : 126-132 17. Young MR, Norris JW (1976) Femoral neuropathy during anticoagulant therapy. Neurology 26:1173-1175

Received 22 April, 1992