Compartment Syndrome of the Leg after Less Than 4 Hours of Elevation on a Fracture Table.

ABSTRACT: Compartment syndrome of the leg is usually associated with significant trauma. It has also been associated with prolonged surgery in the hemilithotomy position. Fracture tables that are used for the internal fixation of proximal femur fractures under fluoroscopy place a patient in this position. This report chronicles two cases of intraoperative compartment syndrome of the leg that was elevated and contralateral to a subtrochanteric femoral fracture. In each case, the syndrome was found at the procedure's conclusion and was addressed with fasciotomies. One patient continued to have neurologic sequelae from the compartment syndrome 2 years later.

Compartment Syndrome of the leg is usually associated with open or closed tibial fractures from blunt or penetrating forces. Even if no fracture is apparent, the usual presentation carries a history of significant trauma. (1) One subtle cause of compartment syndrome that has been reported is positioning on an operating table during prolonged surgery. This subtle cause has been identified in both the lithotomy (2-5) and hemilithotomy positions (6) and is thought to be the result of prolonged elevation of the patient's legs. (7-10) The lithotomy position is commonly used for urologic and abdominal surgeries, whereas in orthopedics the hemilithotomy position allows easy surgical exposure of the hip and proximal femur for intramedullary and extramedullary fracture stabilization under fluoroscopic guidance. (11) Its use is imperative in the placement of proximal and distal interlocking screws under fluoroscopy. The leg contralateral to the fracture is placed on a well-padded stirrup that places pressure on the pos terior aspect of the calf. In this position, the knee and hip are flexed; the hip is abducted and internally rotated. Although this position and the use of fracture tables are safe, previous reports have chronicled this subtle cause of leg compartment syndrome in long surgical cases. (6) In this report, we present two additional cases of nontraumatic compartment syndrome of the leg attributed to the hemilithotomy position on two types of orthopedic fracture tables during internal fixation of subtrochanteric femoral fractures. In both of these cases, the procedure went without difficulty, with shorter operative times than those reported in previously published cases of compartment syndromes.

CASE REPORTS

Case 1. A 22-year-old man was hit by a car while riding his bicycle and sustained fractures of the right distal radius and proximal humerus, as well as a subtrochanteric fracture of the left femur. On physical examination, he was alert and oriented, He had obvious deformity and pain around the distal radius and proximal humerus. The left thigh was swollen, ecchymotic, painful to palpation, and without any evidence of open wound. The pulses distal to the thigh were normal bilaterally, as were results of motor and sensory examination. The patient did not complain of any pain in the left leg, which had normal range of motion and showed no signs of trauma. Radiographs of the left thigh showed a large, unstable comminuted subtrochanteric femoral fracture.

The fractures of the distal radius and proximal humerus were surgically addressed first, with the patient on a regular operating room table. The femoral fracture was then stabilized with an intramedullary hip screw (Smith & Nephew, Memphis, Tenn). For this procedure, the patient was transferred from the regular table onto a traction and orthopedic surgery operating table (Chick, Versailles, Ohio) and placed in the hemilithotomy position with the right leg elevated on a well-padded stirrup. The intramedullary nailing was completed in 3 hours 15 minutes (total anesthesia, 10 hours), and in the recovery room, his initial complaint was pain in the lower extremity that had been elevated. Physical examination at that time documented that the leg bad become swollen and tense. This leg pain increased with palpation and passive toe and ankle movement. As a secondary diagnostic criterion, compartment pressures were measured with a Stryker 295-2 Quick Pressure Monitor Set (Kalamazoo, Mich). The pressures ranged from 60 to 90 mm Hg in each of the compartments.

The patient was returned to the operating room immediately for fasciotomies to release all of the leg compartments. (12) Postoperatively, he complained of paresthesias involving the plantar surface of the right foot. These resolved within 10 days, and at 3 months, he started progressive weight-bearing. At 6 months after the injury, the patient was without complaint and had returned to his employment as a carpenter. At final follow-up 3 1/2 years later, he had a normal gait, symmetric leg lengths, painless ambulation, and a radiographically healed fracture. The right leg fasciotomy wounds were healed, and the patient was without complaints.

Case 2. A 23-year-old man sustained an isolated right subtrochanteric femoral fracture as an unrestrained driver in a motor vehicle accident. On physical examination in the emergency room, he was alert, oriented, and without complaints of injury to the left leg. Vascular and neurologic findings were normal in both legs. The right thigh had no open wounds but was swollen and painful. Radiographs showed that this fracture had a large area of comminution with an unstable configuration (Fig 1).

The operative procedure, using a Zimmer intramedullary reconstruction nail (Warsaw, Ind), done on a Jackson fracture table (Orthopedic Systems Inc, Union City, Calif) with the right leg elevated in a padded stirrup. The procedure lasted 3 hours 45 minutes. At the end of the procedure, but before extubation, a "secondary survey" physical examination was done. During this examination, the left, elevated leg was found to be swollen and tense. A Stryker 295-2 Quick Pressure Monitor Set was used to measure the compartment pressures that ranged between 50 and 80 mm Hg in all four compartments of the leg. The patient was then transferred onto a regular operating room table, and all of the leg compartments were released with fasciotomies. Postoperatively, the patient had global paresthesias on the plantar and dorsal surfaces of the affected foot to the area of the malleoli.

Three months later, the patient continued to have moderate pain in the thigh and paresthesias in the foot. Radiographs at that time showed a healing fracture, and progressive weight-bearing was started. Over the next 3 months, the thigh pain diminished, and he was able to return to work as a brick mason; however, he continued to have a global lack of sensation on the left foot from the malleoli distally.

At final follow-up 2 years after the injury, radiographs showed a healed fracture (Fig 2). The leg lengths were not symmetric, the right side being shorter than the right by 2 cm. The paresthesias that began after surgery had not resolved. His gait was not antalgic, but he reported moderate thigh and foot pain when standing for 3 hours or more. The patient expressed satisfaction with the surgery but did complain that his foot pain compromised the number of hours he could work in a day.

DISCUSSION

Compartment syndrome of the leg usually is attributed to a significant injury resulting in fractures and/or extensive soft tissue injury. (1,11) Because the history of a high-energy trauma gives the physician a high index of suspicion, traumatic compartment syndromes are more easily identified than the ones associated with more subtle causes. Some of the infrequent causes of compartment syndrome that have been identified include fluid shifts from dialysis or fluid replacement in burn patients, and even exercise (3,8-10) Previous reports have documented the occurrence of leg compartment syndromes from placing the patient in the lithotomy position for operations that lasted longer than 6 hours. (2-5) Lett and Shapiro (4) reported a bilateral compartment syndrome that manifested itself a day after a 6 1/2 hour urologic procedure with the patient in the lithotomy position. In orthopedic surgery, one author documented its unilateral occurrence in the elevated leg of a patient who was placed in the hemilithotomy p osition for as little as 6 hours.

A review of this problem in two orthopedic cases in the literature showed that each procedure lasted for at least 5 hours 45 minutes. (6) In our first case, surgery lasted 3 hours 15 minutes, but the total anesthesia time was 10 hours. In the second case, both the procedure and the total anesthesia time were less than 4 hours. The compartment syndromes that are attributed to prolonged positioning on a fracture table are extremely subtle in their onset and are easily missed because the patient is typically intubated and anesthetized. The first case reported here was not found until after extubation, when the patient complained of pain in the unaffected leg. In the second case, the compartment syndrome was found before extubation. Despite prompt recognition and emergency treatment with fasciotomies, one patient continued to have neurologic symptoms 2 years later.

Intraoperative compartment syndrome of the leg caused by prolonged operative positioning is rare. Its subtle onset and lack of symptomatic findings while the patient is anesthetized makes it a complication that could easily be missed in the intraoperative or postoperative period. It is important that the surgical and recovery room teams be aware of this rare complication and have a high suspicion of its possible presence when assessing the perioperative patient.

From the Department of Orthopedics, Indiana University School of Medicine, Indianapolis; and the Department of Orthopaedic Surgery, Kaiser Permanente Hospital, Oakland, Calif.

Reprint requests to Russell Meldrum, MD, Indiana University School of Medicine, Department of Orthopedics, 451 clinical Dr, Room 600, Indianapolis, IN 46022.

References

(1.) Matsen FAI, Winquist RA, Krugmire RBJ: Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am 1980; 62:286-291

(2.) Khalil IM: Bilateral compartmental syndrome after prolonged surgery in the lithotomy position. J Vasc Surg 1987; 5:879-881

(3.) Kikta MJ, Meyer JP, Bishara RA, et al: Crush syndrome due to limb compression. Arch Surg 1987; 122:1078-1081

(4.) Lett RG, Shapiro SR: Lower extremity complications of the lithotomy position: prevention and management. J Urol 1979; 122:138-139

(5.) Lydon JC, Spielman FJ: Bilateral compartment syndrome following prolonged surgery in the lithotomy position. Anesthesiology 1984; 60:236-238

(6.) Dugdale TW, Schutzer SF, Deafenbaugh MK, et al: Compartment syndrome complicating use of the hemi-lithotomy position during femoral nailing. J Bone Joint Surg Am 1989; 71:1556-1557

(7.) Matsen FAI, Mayo KA, Krugmire RBJ, et al: A model compartmental syndrome in man with particular reference to the quantification of nerve function. J Bone Joint Surg Am 1977; 59:648-653

(8.) Murbarak SJ, Carroll NC: Volkmann's contracture in children: aetiology and prevention. J Bone Joint Surg Br 1979; 61:285-293

(9.) Nicholson JT, Foster RM, Heath RD: Bryant's traction. a provocative cause of circulatory complications. JAMA 1955; 157:415-418

(10.) Owen CA, Mubarek SJ, Hargens AR, et al: Intramuscular pressures with limb compression. clarification of the pathogenesis of the drug-induced muscle-compartment syndrome. N Engl J Med 1979; 300:1169-1172

(11.) Dabezies EJ, D'Ambrosia R: Fracture treatment of the multiply injured patient. Instructional Course Lectures, American Academy of Orthopaedic Surgeons. St. Louis, CV Mosby Co, 1986, p 16

(12.) Mubarak SJ, Owen CA: Double-incision fasciotomy of the leg for decompression in compartment syndromes. J Bone Joint Surg Am 1977; 59:184-187

RELATED ARTICLE: KEY POINTS

* Compartment syndromes of the leg can accompany prolonged surgery in the lithotomy and hemilithotomy positions.

* Because the patient is under anesthesia, these can be missed.

* Prompt recognition and treatment of these potentially catastrophic problems is imperative.

* A high index of suspicion is needed for this condition after any case with prolonged elevation of one or both legs.