Compartment syndrome of the thigh after an isolated femoral shaft fracture is a rare finding1. Schwartz et al.2 found only twenty-one cases of thigh compartment syndrome in more than 6000 patients with femoral shaft fracture. Arterial injury has been reported to cause compartment syndrome either directly or indirectly after arterial repair2-5. To our knowledge, acute thigh compartment syndrome secondary to femoral vein rupture has not previously been reported.
We present a patient with acute thigh compartment syndrome caused by bleeding from a rupture of the femoral vein with a concomitant traumatic femoral diaphyseal fracture. The fracture and compartment syndrome were successfully treated with an extensive lateral fasciotomy and open reduction and internal fracture fixation with locked intramedullary nailing, followed by primary reconstruction of the ruptured femoral vein with a saphenous vein graft. The patient was informed that data concerning his case would be submitted for publication, and he provided consent.
Acute compartment syndrome of the thigh is an uncommon condition that is associated with a high rate of morbidity3,6-8. Etiologies of this potentially devastating condition are varied and include femoral fractures, arterial injury, contusion, external compression, intraoperative positioning, and coagulopathy8,9. The diagnosis of acute compartment syndrome in awake patients is often based on its characteristic clinical symptoms, including pain out of proportion to the severity of injury, increased limb circumference, pain with passive muscle stretch, weakness of the involved muscle(s), or sensory deficits in the anatomic distributions of the nerves within the compartment4,8,9. Compartment pressure measurements aid in the diagnosis, especially in unconscious patients. An intracompartmental pressure of 30 mm Hg or above or a difference of less than 30 mm Hg between compartment pressure and mean diastolic pressure is commonly cited as an indicator of compartment syndrome10,11.
Arterial injury is a major cause of acute compartment syndrome of the thigh, which has two major mechanisms. The first is the hemorrhage and subsequent soft-tissue reaction. The second is reperfusion swelling after arterial repair3. This is commonly seen after a popliteal artery injury and repair, when leg compartment syndrome often develops as the muscle tissue is reperfused following a period of no or poor vascularity after the arterial repair.
Theoretically, the mechanisms of venous injury that cause compartment syndrome might be: (1) the blood volume from the hemorrhage, (2) resultant soft-tissue swelling from the hematoma, and (3) lack of blood flow out from the compartment caused by venous disruption.
The classical symptoms of arterial injury include pulsatile hemorrhage, expanding hematoma, palpable or audible thrills, and a pulseless limb12. Compared with arterial rupture, venous rupture usually presents more insidiously, with nonpulsatile hematoma and with lower leg and foot swelling. These symptoms can be easily overlooked in the setting of an acute femoral shaft fracture, resulting in delayed diagnosis and devastating consequences. In our patient, none of the above-mentioned arterial signs were initially present except for an expanding hematoma. The combination of a negative CTA finding with strong distal pulsations in the left leg essentially ruled out an arterial injury. The diagnosis of a venous injury could not be made definitively on CTA because elevated intracompartmental pressures might have compressed the vein or stopped its bleeding. In clinical practice, venous injuries are accurately diagnosed only by venography or vascular duplex ultrasound examination13. Both studies are time-consuming and must be performed on patients with stable vital signs.
In our institute, antegrade nailing through a lateral surgical approach is the most frequently used method to fix femoral shaft fractures14. Familiarity with this approach allowed us to quickly stabilize the fracture in less than twenty minutes. However, with the patient in the lateral decubitus position, it was very difficult to perform venous exploration. Therefore, the patient was changed to the supine position for vascular exploration and venous grafting. An alternative surgical strategy would be to place the patient in the supine position so that venous exploration and fracture fixation could be performed without repositioning and redraping15; the venous exploration would be done before the fracture fixation. This approach could decrease blood loss because the major source of bleeding would have been controlled earlier. Although we successfully saved the left lower limb of our patient, it would be reasonable to use the supine position and explore the femoral vessels prior to fracture fixation in similar cases.
Although rarely encountered, femoral vein rupture should be considered when dealing with compartment syndrome of the thigh in the setting of an acute femoral fracture. A high index of suspicion and meticulous examination are key to prompt diagnosis and proper treatment.