Figure - available from: Case Reports in Orthopedics
This content is subject to copyright. Terms and conditions apply.
CTA of the gluteal vasculature showing intact vasculature with obvious swelling of the gluteal muscles within the left gluteal compartment, compared with the right.
Source publication
A male patient in his fifties presented to his local hospital with numbness and weakness of the right leg which left him unable to mobilise. He reported injecting heroin the previous morning. Following an initial diagnosis of acute limb ischaemia the patient was transferred to a tertiary centre where Computed Tomography Angiography was reported as...
Citations
... This often progresses to paresthesia and paralysis of the sciatic nerve. The cornerstone of treatment is prompt diagnosis and early decompressive fasciotomy [9][10][11] to avoid debilitating complications such as permanent paralysis and/or muscle tissue loss [12,13], rhabdomyolysis often leading to myoglobinuria and acute renal failure, and potentially death [14]. ...
... Other studies suggest that a delay in diagnosis would also lead to elective medical treatment, as the potential risks associated with fasciotomy may outweigh the benefits [15,20,21]. This contrasts with Lawrence et al. who reported immediate clinical improvement in a patient with neurologic symptoms after a 56-h delayed fasciotomy [11]. This suggests that fasciotomy may play a crucial role in the management of GCS but needs to be chosen on a case-by-case basis, after careful assessment. ...
Purpose
Gluteal compartment syndrome (GCS) is a rare but devastating condition with a paucity of literature to help guide diagnosis and management. This study aims to identify and describe the risk factors and patient characteristics associated with GCS to facilitate early diagnosis.
Methods
This is a retrospective case series of patients undergoing gluteal compartment release between 2015 and 2022 at an academic Level I trauma center. Chart reviews were performed to extract data on patient demographics, presenting symptoms, risk factors, operative findings, and postoperative outcomes.
Results
14 cases of GCS were identified. 12 (85.7%) were male, with a mean age of 39.4 ± 13 years and a mean BMI of 25.1 ± 4.1 kg/m². 12 (85.7%) patients did not present as traumas and only 3 had ≥ 1 fracture. 9 patients reported drug use. Hemoglobin (Hgb) (11.7 ± 4 g/dL) was generally low (5 had Hgb < 10 g/dL). Creatine kinase (49,617 ± 60,068 units/L) was consistently elevated in all cases, and lactate (2.8 ± 1.6 mmol/L) was elevated in 9. 13 had non-viable muscle requiring debridement. Postoperatively, the mean ICU length of stay was 12 ± 23 days. 2 patients died during admission and all remaining patients required discharge to rehabilitation facilities.
Conclusion
GCS is more likely to present in a young to middle-aged, otherwise healthy, male using drugs who is either found down or experienced an iatrogenic injury. Recognizing that GCS is different from that of the leg, in terms of etiology, may help avoid delays in diagnosis and treatment.
... Gluteal compartment syndrome usually occurs after vascular injury, surgical positioning, and prolonged immobilization from alcohol or drug immobilization [1][2][3]. Early diagnosis and treatment may prevent sciatic nerve palsy and life-threatening hyperkalemia secondary to rhabdomyolysis [4,5]. ...
Compartment syndrome usually occurs after trauma, fracture, or compression injuries. To the authors' best knowledge, this is the first reported case in the medical literature of a combined gluteal and posterior thigh compartment syndrome after an accidental fall without an associated fracture. A 65-year-old man attended the emergency department of the general hospital in a remote island complaining of a swollen painful thigh. He reported that 24 h previously he had an accidental slip and fall on his overstretching right leg. Physical examination revealed right posterior thigh edema, tenderness, paraesthesia, and firmness to palpa-tion. Any attempt to flex the knee provoked pain of intensity 10/10. In addition, there was blue discoloration over the lower half of the gluteal region, non-compressible tense swelling, and pain of intensity 10/10 elicited with passive range of motion of the hip. Compartment syndrome was considered and consequently, fasciotomy of the gluteal and posterior thigh compartments was performed under spinal anesthesia. Compartment syndrome is a surgical emergency. In a remote island, it must be considered and treated early because any delayed diagnosis may lead to loss of an extremity, kidney failure, sepsis and even death.
... Lachiewics et al. in 1991 stated that they believed the symptoms would resolve with medical management alone; however 2 of their 5 patients treated conservatively developed permanent deficit [80] . Lawrence et al. presented a case of fasciotomy performed 56 hours after the onset of neurologic symptoms resulting in immediate clinical improvement [17] . This suggests that fasciotomy may still have a role in the treatment of patients with a delayed diagnosis however potential benefits must be weighed against risk of complications after fasciotomy. ...
Introduction:
Gluteal compartment syndrome is a rare but devastating condition with limited characterization in the literature. The purpose of our systematic review, case series, and meta-analysis is to synthesize the current literature and provide recommendations on how to prevent gluteal compartment syndrome, identify at-risk patients, and avoid delays in diagnosis and treatment.
Methods:
International Classification of Disease codes were used to identify patients at our institution. PubMed, MEDLINE, and the Cochrane Library were searched to identify case reports between 1972 and March 1st, 2018. Cases were analyzed based on demographics, etiology, presentation, symptoms, diagnosis, treatment, and outcomes.
Results:
139 cases - 13 from our institution and 126 previously published - were included. The most common etiologies were postoperative (41%), prolonged immobilization secondary to substance abuse or loss of consciousness (35%) and trauma (19%). 89% were male, mean age was 45 years (range, 16-74), and mean body mass index was 41 kg/m2. Rhabdomyolysis and sciatic neuropathy were identified in 94% and 74% of patients, respectively. Fasciotomy was performed in 80% of patients. Overall, 93% of patients survived. However, 41% of patients suffered prolonged neurologic dysfunction. In patients with an initial neurologic deficit, there was a higher rate of permanent neurological deficit in patients treated medically than those treated surgically (12/14 vs 29/61, p=0.0153), but no statistical difference in mortality (0/14 vs 4/61, p=1). In patients without initial neurologic deficit, there were no statistical differences in rates of permanent neurological deficit (0/7 vs 2/20, p=1) or mortality (0/7 vs 3/20, p=0.545) between those receiving medical or surgical treatment.
Discussion:
Gluteal compartment syndrome is an orthopaedic emergency that may be more prevalent and associated with higher morbidity and mortality than previously recognized. Risk factors may include prolonged surgical duration, immobilization secondary to substance abuse, and pelvic trauma. Intraoperative precautions and postoperative surveillance are recommended in obese patients undergoing prolonged procedures. Fasciotomies improve neurologic outcomes in patients presenting with an initial neurologic deficit. In patients who are neurologically intact on presentation, medical management with neurologic function surveillance may be the optimal initial treatment. Fasciotomies do not impact mortality. Additionally, a treatment algorithm is provided.
... Clinical manifestations of gluteal compartment syndrome such as resultant pain and swelling in the lower limb can easily be misdiagnosed as deep vein thrombosis (5). In this case low molecular heparin administration has been associated with poorer prognosis of the compartment syndrome (6). Although, medical history is paramount of importance to recognize this entity. ...
Background: Gluteal compartment syndrome (GCS) is a rare entity, while the nonspecific clinical manifestations can lead to misdiagnosis and delay of treatment, compromising the morbidity and mortality rate. GCS impairs large muscles and this can rapidly result in severe rhabdomyolysis, renal failure, multiple organ failure and even death.
Case Presentation: A 47-year-old female patient was admitted to our emergency department on bad general condition due to neurologic deterioration of her right leg. After medical history record, laboratory and imaging testing diagnosis of GCS was settled. Although, there was remarkable delay from the onset of symptoms till to the diagnosis confirmation for several reasons. The delay, the hemodynamic instability, the acute renal failure, the important comorbidities and the skin condition led us to treat this patient conservatively. The patient underwent hemodialysis, while we discontinued her previous medication, which may have worsened rhabdomyolysis. One year after admission, she could ambulate without any support with minor complaints.
Conclusion: Gluteal compartment syndrome is a rare entity and high degree of suspicion is needed for timely diagnosis and treatment. Fasciotomy is the gold standard treatment and surgeons should be able to perform this intervention in urgent setting. Medical history is paramount of importance for timely diagnosis. Surgeons should be aware that patient's mal positioning during surgery can lead to this devastating complication. Deep vein thrombosis should be excluded and low molecular weight heparin should not be initiated without confirmation of the diagnosis. Drug induced rhabdomyolysis should be taken into consideration in cases of intoxication with specific medicines. In cases with delayed presentation there is no consensus for the appropriate treatment. Decision should be based on patient's general condition, the condition of the skin, the patient's comorbidities and trauma center facilities.
... Gluteal CS (GCS) is one of the rarest forms and most of the cases result from prolonged immobilization and local pressure on the gluteal muscles due to altered consciousness, improper surgical positioning, blunt or penetrating trauma to pelvis and buttocks, and post vascular procedures. [1][2][3][4][5][6][7][8] Given the rarity of the GCS and lack of knowledge about this entity among health-care professionals and difficulties at detailed history taking and physical examination in the presence of altered consciousness at the patients, the diagnosis is often delayed or unavailable. ...
... And other causes include spontaneous gluteal artery rupture in Ehlers-Danlos syndrome, necrotizing fasciitis of gluteal muscles and sickle cell anemia. [1][2][3][4][5][6][7][8]24] The gluteal compartment is composed of three separate sub compartments: The gluteus maximus, the gluteus medius and minimus, and the tensor fascia lata. [22] Sciatic nerve and the superior and inferior gluteal neurovascular bundles are extra compartmental and lays deep to the gluteal compartment but the sciatic nerve and its blood supply are prone to external compression. ...
... Neurological signs of sciatic nerve compression such as sensorial or motor deficits are the late findings. [8,11,21] Sensory deficits generally occur before the motor deficits sets in and some authors believe that the loss of two-point discrimination is more typical in CS than in raised intracompartmental pressure alone without CS. [25,26] Pseudoaneurysms may demonstrate thrills, bruits, or pulsations during palpation and auscultation. ...
Gluteal compartment syndrome (CS) secondary to the superior gluteal artery (SGA) injury and pseudoaneurysm formation is a very rare condition. When it does occur, it usually manifests with acute and life-threatening hemorrhage resulting in early hypov-olemic changes. Delayed presentation of the gluteal CS (GCS) after trauma has been described in the literature seldom and these cases were demonstrated with sciatic nerve palsy, hemodynamic instability, decreased hemoglobin levels, increasing buttock pain, and a large gluteal hematoma. In this report, we present a case of GCS presenting with the palsy of the peroneal division of the sciatic nerve secondary to SGA pseudoaneurysm following ballistic injury, with a delay of nearly 20 days in diagnosis and treatment with normal hemodynamic findings. The patient required emergent angiographic embolization and then fasciotomy which were approx-imately 13 days after the onset of the symptoms. The patient made a positive recovery with no further neurologic deterioration and none local wound or systemic complications. This case emphasizes the importance of early diagnosis and treatment of this rare condition.
... Normal values have been reported to be 13-14 mm Hg [68]. Emergent fasciotomies are considered the treatment of choice, and even in delayed presentation after 56 hours, they provided a favorable outcome [69]. Therefore, Panagiotopoulos et al. on their case report with residual sciatic nerve palsy despite fasciotomies reported that nonoperative treatment should have limited place due to high risks and minimal benefits [66]. ...
Compartment syndrome can be hidden under various conditions or affect unusual anatomical locations or procedures. Systemic diseases such as diabetes mellitus, hypothyroidism, systemic capillary leak syndrome (Clarkson’s syndrome), HIV, hematological/leukemic disorders, or systemic sclerosis can all be complicated with compartment syndrome. Unusual anatomical locations such as gluteal or paraspinal regions can be affected as well as atypical muscles (medial head of gastrocnemius-tennis leg or peroneus longus). Unusual clinical conditions include exertional compartment syndrome (acute or chronic), spontaneous idiopathic (of unknown origin), neonatal, or following rare infections. Medications which can provoke this syndrome include statins and neuroleptic psychiatric drugs. Moreover, procedures which can very rarely cause compartment syndrome are coronary arterial bypass grafting, neuromonitoring, and total knee replacement. Innocuous distal radius fractures in the elderly have been reported to be complicated by acute compartment syndrome. All these conditions and scenarios should raise awareness to medical personnel for possible compartment syndrome when dealing with patients with unexplained and out of proportion pain along with highly suspicious symptoms. Symptoms and treatment do not differ from the ones in usual compartment syndrome presentation. However, delays in diagnosis have negative implications in regard tothe final outcome.
... Accurate catheter placement within the affected compartment is carried out using a strict aseptic technique [67]. In the presence of a fracture, the literature would suggest that the catheter tip should be placed within 5 cm of the level of the fracture, as this will give the peak measure reading within the compartment [4,[68][69][70]. Others advocate this results in a false high reading due to the fracture haematoma [71]. ...
... Early data suggested using an absolute ICP threshold of 30-40 mmHg [30,50,54,58,[73][74][75]. However, it was subsequently noted that a patient's tolerance for an absolute pressure reading does vary widely and was intrinsically linked with the systemic blood pressure or perfusion pressure [51,69,[76][77][78]. Whitesides et al. documented the use of the differential pressure (∆P), calculated as diastolic pressure -intra-compartmental pressure [76]. ...
... Whitesides et al. documented the use of the differential pressure (∆P), calculated as diastolic pressure -intra-compartmental pressure [76]. Following on from this, data then proposed a differential pressure of 10-35 mmHg as diagnostic [69,78,79]. However, it has been noted that the differential pressure will possibly be increased in traumatised or ischaemic muscle. ...
Compartment syndrome is a complex physiologic process with significant potential harm, and though an important clinical problem, the basic science and research surrounding this entity remains poorly understood. This unique open access book fills the gap in the knowledge of compartment syndrome, re-evaluating the current state of the art on this condition. The current clinical diagnostic criteria are presented, as well as the multiple dilemmas facing the surgeon. Pathophysiology, ischemic thresholds and pressure management techniques and limitations are discussed in detail. The main surgical management strategy, fasciotomy, is then described for both the upper and lower extremities, along with wound care. Compartment syndrome due to patient positioning, in children and polytrauma patients, and unusual presentations are likewise covered. Novel diagnosis and prevention strategies, as well as common misconceptions and legal ramifications stemming from compartment syndrome, round out the presentation.
Unique and timely, Compartment Syndrome: A Guide to Diagnosis and Management will be indispensable for orthopedic and trauma surgeons confronted with this common yet challenging medical condition.
... 6,7 Both the nerve and its blood supply are vulnerable to compressive forces. 6,8 Any delay in decompressing the gluteal compartments and sciatic nerve may lead to irreversible ischemia. Gluteal intracompartmental pressures are often unreliable; therefore, the diagnosis of gluteal compartment syndrome is based on the clinical findings and examination. ...
... On a broader topic, several authors advocate against fasciotomies in the treatment of compartment syndrome with delayed presentation (longer than 35 hours from the onset of compartment syndrome) due to high complication rates and limited evidence of subsequent functional improvement. 8,14 We, therefore, recommend to attempt nonoperative management in this setting with aggressive physical therapy and a steroid regimen. ...
As gluteal augmentation continues to gain in popularity among patients seeking aesthetic enhancements, a thorough knowledge of the postoperative complications associated with this procedure is crucial. This case report concerns a 31-year-old woman who suffered bilateral foot drop secondary to sciatic neuropathy and as a result was wheelchair-bound for several months, following gluteal autologous fat grafting in the Dominical Republic. One year later, the patient had persistent left foot drop and sensory deficits. This is a devastating but seldom reported complication that all plastic surgeons need to be aware of when performing this operation.
Objective:
To characterize the patient population with substance related found-down extremity compartment syndrome (FDECS) and report on their treatment and outcome.
Data source:
This systematic review was performed in accordance with the PRISMA guidelines. Articles in the English language were identified by searching three online databases, EMBASE®, PubMed Publisher and Cochrane Central, in September 2019.
Study selection:
Studies involving substance-related FDECS were included. Exclusion criteria were as follows: patient age <18 years, not original studies, no full text available, technical reports, traumatic AECS, chronic exertional compartment syndrome and vascular AECS.
Data extraction:
There were 61 studies included with 166 cases of FDECS. Two investigators screened and extracted data independently according to a standardized template. Disagreements were addressed by an attempt to reach a consensus, and involvement of a third reviewer. Studies were quality assessed with "Quality Assessment tool for Case Series Studies".
Data synthesis:
Descriptive statistics were reported using Excel.
Conclusion:
Substance-related FDECS is often occurring in young adults. Data from this review found that most of the patients were already diagnosed with substance use disorders and/or psychiatric disorders. There should be a high index of suspicion of FDECS in patients presenting after prolonged immobilization.
Level of evidence:
Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
Gluteal compartment syndrome is an uncommon condition and can be difficult to diagnose. It has been diagnosed after trauma, vascular injury, infection, surgical positioning, and prolonged immobilization from drug or alcohol intoxication. The diagnosis is based on clinical findings and, in most cases, recognizing these symptoms and making a diagnosis early is critical to a complete recovery.
Case presentation:
A 53-year-old male who underwent left foot surgery had severe pain to his contralateral hip and posterior gluteal compartment radiating to the right lower extremity immediately postoperative. He was positioned supine with a "bump" placed under his right hip to externally rotate his operative leg during the surgery. Due to the patient's complex past medical history, a presumptive diagnosis of a herniated disc and/or compression of the sciatic nerve was made as a cause for the patient's pain. This resulted in a misdiagnosis period of 36 h until the patient was diagnosed with unilateral gluteal compartment syndrome. Performing a fasciotomy was decided against due to the increased risk of complications. The patient was treated with administration of IV fluids and closely monitored. On post-op day 6, the patient was discharged. At three months post-op, the patient was walking without a limp and he had no changes in his peripheral neurologic examination compared to his preoperative baseline.
Conclusion:
Gluteal compartment syndrome is a surgical emergency that must be considered postoperatively especially in obese patients with prolonged operation times who experience acute buttock pain. The use of positional bars or "bumps" in the gluteal area should be used with caution and raise awareness of this complication after orthopedic surgeries.
