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Compartment syndrome of the thigh. A case report with delayed onset after stable pelvic ring fracture and chronic anticoagulation therapie
© Burghardt et al; licensee BioMed Central Ltd. 2010
Received: 19 February 2010
Accepted: 27 July 2010
Published: 27 July 2010
Compartment syndrome of the thigh is a rare occurrence potentially leading to devastating functional restrictions. There is a wide spectrum of reported conditions leading to increased tissue pressure in the thigh possibly resulting in a compartment syndrome, ranging from deep venous thrombosis to blunt injuries and femoral fractures. We report a case of a delayed development of a compartment syndrome of the thigh secondary to an undisplaced anterior pelvic ring fracture and chronic anticoagulation therapy in a 94-year-old woman. Regarding anticoagulation therapy there are numerous reports about the spectrum of bleeding complications during therapy, however this severe complication has to our knowledge not been reported previously. Treatment consisted in immediate fasciotomy and subsequently secondary wound closure.
Blunt trauma or femoral fractures, frequently lead to soft tissue damage and contusion of varying degrees of severity. In comparison to the lower leg the development of a compartment syndrome in the thigh however is particularly rare. In the lower leg the muscle compartments are tighter enclosed by the muscle fascia as in the thigh and the lower dilatability of this muscle fascia promotes the process of the development of a compartment syndrome. As the compartments of the thigh are larger in space and more compliant, they are more sustainable against expanding haematoma . If the intra-compartmental pressure increases and exceeds the perfusion pressure, the microcirculation becomes oppressed and the tissue viability is jeopardized. Volkmann in 1881  was the first to describe these pathophysiologically coherences.
Compartment syndromes of the thigh are rare but they bear the potential danger of serious morbidity and potential mortality if not recognized early and treated immediately. Operative treatment includes immediate fasciotomy of the affected compartments, complete drainage of the haematoma, careful arrest of bleeding, and delayed secondary closure of the skin.
As the compartment syndrome of the thigh is a particular rare occurrence, most articles in the literature report about specific cases [1, 3–9], or present small case series , screening protocols , functional outcome  or a clinical spectrum [10, 13]. To our knowledge a case of a delayed development of an acute compartment syndrome of the thigh after a stable pelvic ring fracture and chronic anticoagulation therapy has not been reported previously.
In cases were the patient is unconscious at the intensive care unit a compartment syndrome can stay unrecognized possibly causing devastating outcome , as the patient can not express main symptoms like disproportional pain, paraesthesia or even paralysis. Only the palpatoric tension of the affected muscle is detectable. These cases must be taken into special account and the measurement of the compartment pressure has an important role in those cases for the diagnostic. Regarding the common literature addressing this topic the measurement of the intracompartmental pressure is the gold standard for the diagnosis . However the reliability of these measurements is questionable, as especially in multiple traumatized patients the systolic blood pressure supported by catecholamines can pretend a stable hemodynamic situation neglecting a possibly severe disregulated microcirculation . In addition there is no consensus in the literature about a specific intracompartmental point pressure or a rule regarding the diastolic blood pressure or the arterial middle pressure, clearly indicating the need of fasciotomy . In our case we initially suspected a deep vein thrombosis and not a compartment syndrome. Therefore we decided for a CT scan. After the diagnosis surgery was performed immediatly and no further diagnostic was performed. Usually suspecting a compartment syndrome calculating the local perfusion pressure by measuring the the mean arterial pressure and the intramascular pressure is the gold standard.
Because of the wide variety of conditions in patients with huge differences in the physiological strength (young men in a car accident versus a 94-year-old women with a stable pelvic fracture) and the very limited numbers of cases with a compartment syndrome of the thigh explains why it is impossible to identify strict criteria for the need of a fascitomy. However the literature agrees that the damage caused by fasciotomy in a patient in which the tissue would not have become necrotic is far outweighed by the morbidity possibly associated by a full-blown compartment syndrome . In a borderline compartment syndrome not only the intracompartmental pressure but close meshed checks of the sensormotor function of the affected leg as well as the typical clinical symptoms are essential for the indication of a fasciotomy.
In our patient the compartment syndrome developed with several days delay. This we hypothezised might be explained by the patient's clinical course. During the first days the patient was immobilized with bed rest. During remobilisation the vessels injured by the initial trauma started to bleed again, thereby creating a haematoma which followed gravity into the thigh. In our case the neurological symptoms resolved quickly after the decompression and no muscle necrosis were detected. However in this case the morbidity was caused by the high age of the patient resulting in multiple complications through a prolonged wound healing. Schwartz has already emphasized that infection is a further problem in the postoperative course in patients with a compartment syndrome. He reports local infection rate of 66% . Although we were not able to detect any significant tissue necrosis in our patient we suppose that prolonged ischemia may have further compromised the microvascular perfusion in this old patient with already existing vascular sclerosis thus drastically increasing the risk of wound infection.
We observe bleeding complications associated with antikoagulative therapy, the literature presents only few cases in this context. As an yet unreported complication of a compartment syndrome of the thigh secondary to an undisplaced anterior pelvic ring fracture and chronic anticoagulation therapy, we feel this case an important contribution to the literature.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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