Acute compartment syndrome of the thigh in a rugby player

Abstract

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

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 complications^30–34 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).

Figure 1.

Right anterior thigh immediately following fasciotomy on the day of injury.

Figure 2.

Skin grafted wound 2-months postinjury.

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).

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}

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 frequently advocated to restore normal capillary perfusion.^{41 57 73} Poor outcomes have been associated with delayed surgical intervention^{57 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 literature^{4 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.

• 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.