doi:10.1016/j.jemermed.2007.10.081
Copyright © 2008 Elsevier Inc. All rights reserved.
Clinical Communications: Adults
Exertional compartment syndrome of the thigh: A rare diagnosis and literature review
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Timothy W. King MD, PhD
, †, Oren Z. Lerman MD, †, Joseph J. Carter MD†, ‡ and Stephen M. Warren MD, †, 
†Bellevue Hospital, New York, New York
‡Department of General Surgery, New York University School of Medicine, New York, New York
Institute of Reconstructive Plastic Surgery, New York University School of Medicine, New York, New York
Received 27 April 2007;
revised 23 September 2007;
accepted 5 October 2007.
Available online 2 July 2008.
Abstract
Exercise-induced acute compartment syndrome of the thigh is an uncommon entity. We present a rare case of bilateral exercise-induced three-compartment syndrome of the thighs that required fasciotomies. The objective of this study was to understand the history, physical examination, signs, symptoms, pathophysiology, diagnosis, and treatment of compartment syndrome and rhabdomyolysis. A 42-year-old man presented to the Emergency Department (ED) complaining of worsening pain and swelling in both thighs 45 h after performing a lower extremity exercise regimen. The patient's thighs were tender and swollen, but there was no ecchymosis or evidence of trauma. Admitting serum creatinine kinase (CK) was 106,289 U/L. Treatment for rhabdomyolysis was initiated. The next day, he complained of escalating bilateral thigh pain. Repeat serum CK was 346,580 U/L. The patient was diagnosed with bilateral thigh compartment syndrome and immediately taken to the operating room for fasciotomies. Postoperatively, the patient's symptoms improved rapidly and his serum CK quickly returned to normal. His incisions were closed and he returned to normal activities of daily living. Because exercise-induced compartment syndrome is an extremely rare diagnosis with a high risk of poor outcome, this article serves to emphasize the importance of considering this diagnosis during the work-up of patients presenting to the ED with rhabdomyolysis.
Keywords: exercise; compartment syndrome; acute; thigh; rhabdomyolysis
Figure 1. Serum creatinine kinase levels. Day “0” is the time of triage in the Emergency Department (ED). Dashed line represents unmeasured serum creatinine kinase before admission (for simplicity, serum creatinine kinase levels before arrival in the ED has been depicted as a straight line). Patient reported and physician documented pain, pressure, and pain with passive movement have been added to this line graft; however, we caution the reader to avoid the temptation to associate absolute serum creatinine kinase values with the appearance of these signs and symptoms.
Figure 2. Photographs of the patient 7 days after fasciotomy for subacute exercise-induced compartment syndrome. (A) bilateral medial incisions, (B) left thigh before V.A.C.® therapy placement, (C) left thigh after V.A.C.® therapy placement. The patient's bilateral medial incisions were closed on postoperative day #7. The bilateral lateral incisions were closed on postoperative day #20.
Figure 3. Instructions for using an intravenous alarm control (IVAC) pump or A-line setup on a standard cardiac monitor to measure compartment pressures (based upon Reference 14).
Table 1.
Causes of Compartment Syndrome
Modified from Nau et al. and Matsen et al. (4,10).
DVT = deep vein thrombosis; DIC = disseminated intravascular coagulation.
Table 2.
Compartments, Contents, and Compression of the Thigh
Modified from Presnal and Heavilon (5).
Table 3.
The Seven “P”s of Compartment Syndrome
Table 4.
Causes of Rhabdomyolysis
Modified from Wise and Fortin (6).
Reprint Address: Stephen M. Warren,
MD, Institute of Reconstructive Plastic Surgery, New York University, Medical Center, 560 First Avenue, THC-169, New York, NY 10016
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