Gluteal compartment syndrome with severe rhabdomyolysis

Abstract

Gluteal compartment syndrome is a rare entity but a recognised complication of prolonged immobilisation. It can present as renal failure as a result of severe rhabdomyolysis and can lead to sepsis and death. We report a case of gluteal compartment syndrome in a 25-year-old man who was found unconscious following intoxication with alcohol and cocaine of an unknown duration. He presented with tense tight left buttock swelling, right thigh swelling, cold immobile extremeties and acute renal failure. Immediate left gluteal, thigh and calf fasciotomy resulting in an improvement of lower limb and renal function.

Background

Acute compartment syndrome is a surgical emergency resulting from increased pressure in a closed osseofascial compartment leading to reduced capillary blood flow below the threshold for tissue perfusion. Gluteal compartment syndrome is rare and often difficult to diagnose. It is usually seen in patients who have been immobilised for a long duration after alcohol or opioid intoxication, incorrect position during orthopaedic or urological surgeries having long operative time, following trauma and due to sickle-cell disease associated muscle infarction. Diagnosis is challenging in unconscious patients where symptoms like pain on passive stretch or paraesthesia are absent. The critical level of the absolute intracompartmental pressure is unclear. It is recommended to use a differential pressure of 30 mm Hg relative to the patients’ diastolic pressure. When compartment syndrome is suspected immediate fasciotomy is required to improve the overall outcome.

Case presentation

A 25-year-old Caucasian male was found unconscious in his house, lying on his left side after alcohol and cocaine intoxication. Paramedics found ST elevation on ECG and he was admitted to a local cardiac centre with a Glasgow Coma Score of 3 (E1V1M1) and was immediately intubated. His vital signs showed a heart rate of 48/min, blood pressure of 60 systolic and ST elevation. Initial examination showed a tight tense left buttock, swelling of the right thigh and cool extremeties with weak peripheral pulses (figures 1 and 2). It was also noted that he had a pressure ulcer on his medial aspect of right knee and medial aspect of the left ankle. These pressure ulcers were in keeping with the position in which he was found unconscious.

Figure 1.

Pressure ulcer on the right leg.

Figure 2.

Preoperative image of the left buttock with tense swelling and skin changes.

Investigations

Investigations revealed deranged electrolytes, with a potassium of 8.6 mEq/L, pH 7.0, base excess of 16 mEq/L and creatine kinase of 380 000 IU/L with myoglobinuria.

Treatment

Immediate resuscitation was commenced with insulin, dextrose and sodium bicarbonate. The severe rhabdomyolysis was treated with aggressive re-hydration and alkaline diuresis. The patient was promptly admitted to the cardiac intensive treatment unit and subsequently transferred to our unit (1.5 h after admission) and was reviewed by the plastic surgery team. The clinical findings of left buttock swelling with some swelling of the right thigh was confirmed, his extremities were cold and hand-held Doppler assessment revealed an absent posterior tibial artery on left side. On the right Doppler assessment was normal. A diagnosis of severe rhabdomyolysis due to gluteal compartment syndrome was made and the patient was taken to theatre for fasciotomy. Operative findings revealed necrotic gluteal muscle in the left gluteal compartment, which was debrided, the sciatic nerve being identified and preserved. The wound was left open for a planned relook 48 h later (figures 3 and 4). The right thigh and calf compartments were released but the muscles were not compromised.

Figure 3.

Partial necrosis of gluteal maximus muscle.

Figure 4.

Image taken after complete debridement.

The patient remained on ITU, requiring inotropic support. The arterial circulation in both lower limbs improved. His renal function remained deranged and the patient was started on haemofiltration. The fasciotomy wounds were re-explored after 48 h, and limb fasciotomy wounds were closed. By day 5 inotropic support had ceased and he was discharged to the renal ward for continuing dialysis. His right lower limb function had improved but he developed foot drop on the left side.

Outcome and follow-up

Figures 5 and 6 show the gradual improvement in the creatine kinase and potassium levels and the renal function continued to improve on regular dialysis. The wounds healed, his left foot drop continued to improve and he was discharged.

Figure 5.

Potassium trend from postperative days 1–8.

Figure 6.

Creatine kinase trend from postoperative days 1–8.

Discussion

Gluteal compartment syndrome results from an increase in interstitial fluid pressure within the gluteal compartment exceeding that of the perfusion pressure leading to loss of tissue function. The gluteal compartment essentially consists of three separate compartments as shown by cadaveric studies. It is covered by an unyielding fascia (continuation of fascia lata) which splits the compartment into three: gluteus maximus, gluteus medius and gluteus minimus and tensor fascia lata.² Increase in swelling and oedema leads to an increase in pressure in this compartment and can cause extensive damage to the muscle leading to severe rhabdomyolysis. The large bulk of the gluteal muscle adds to the morbidity associated with the condition.³

The sciatic nerve lies between the pelvis-external rotator complex and the deep surface of the gluteus maximus, therefore, can be damaged severely due to increased pressure in this compartment. More than half the patients with gluteal compartment syndrome suffer from neurological symptoms due to sciatic nerve damage and symptoms persist if there is delay in treatment.⁴

Gluteal compartment syndrome is found to occur most commonly after prolonged immobilisation especially after intoxication. Other causes include improper positioning of the patient during prolonged urological, gynaecological and orthopaedic procedures, superior gluteal artery rupture, sickle cell disease associated infarct and rarely due to trauma. Obesity, unconscious patient and epidural anaesthesia are associated risk factors and can make diagnosis more challenging.

Clinical features include severe buttock pain at rest, paraesthesia and sciatic nerve symptoms in prolonged cases. Physical findings include tense buttock swelling, with painful hip movements. Late presentation may show skin changes in the form of bruising or ischaemia, distal pulses may not be palpable and signs of sciatic nerve damage may appear. In an unconscious patient in the absence of the classic symptoms of compartment syndrome, one should not hesitate in measuring the individual compartment pressures.

As the muscle becomes ischaemic, fluid accumulates in the compartment leading to massive third space loss which leads to hypotension and shock. The muscle cells release potassium and myoglobin on lysis leading to severe acidosis. Myoglobin can get deposited in the distal renal tubules and can lead to acute renal failure. Appropriate resuscitation of the patient with intravenous fluids, insulin and alkaline diuresis along with monitoring of blood pressure, urine output and pH is imperative. Once diagnosed, prompt treatment in the form of decompression of all the three gluteal compartments by fasciotomy should be performed to avoid adverse outcomes. Early fasciotomy limits further irreversible damage. Figure 7 demonstrates the incision used for decompressing the gluteal compartment, to facilitate adequate exposure of the compartment and identification of the sciatic nerve. All the necrotic tissue should be debrided and further look in 48 h should be performed to ensure complete debridement.

Figure 7.

(A) Kocher-Langenbach incision for gluteal fasciotomy. (B) The incision allows the identification of the sciatic nerve.³

Learning points.

• Gluteal compartment syndrome is a rare condition that poses a great diagnostic challenge.

• It is associated with high morbidity.

• It is important to have a high degree of suspicion in individuals at risk so that it can be diagnosed at an early stage to avoid any complications.