Delayed Presentation of Acute Gluteal Compartment Syndrome

Background

Compartment syndrome is a condition in which increased compartment pressure within a confined space compromises the circulation and viability of the tissues within that space [1]. The numerous ways compartment syndrome may present lead to a masking of its true etiology. Early recognition by healthcare providers is essential in preventing morbidity and mortality. When compartment syndrome is suspected, immediate fasciotomy is required to improve the overall outcome [2]. Muscles and nerves tolerate ischemia for up to 4 hours with limited sequelae; however, 8 hours of ischemia results in irreversible damage [3]. There is inadequate perfusion and relative ischemia when the tissue pressure within a closed compartment rises to within 10–30 mm Hg of the patient’s diastolic blood pressure [4]. Rhabdomyolysis may result from this ischemia, generating a large release of potassium and a heme-containing protein, myoglobin, leading to severe acidosis and renal tubule cast formation, respectfully. Myoglobin can get deposited in the distal renal tubules and can lead to acute renal failure [2].

Case Report

OUTCOME AND FOLLOW-UP:

The Figures 1–6 provided show the gradual improvement of creatinine, CPK, WBC, and urine output levels throughout the hospital stay. Hemodialysis was a temporary measure in this case and eventually could be withheld with return to the patient’s baseline creatinine of less than 1. The gluteal incision healed well, and the patient’s ambulation continued to improve with assistance of outpatient physical rehabilitation, where flexibility and strengthening exercises were utilized. The patient was followed for approximately two months before being lost to follow-up. At the last follow-up appointment, the patient had active but weak dorsiflexion/plantarflexion of the right ankle, moderately reduced right-sided quadriceps function, normal vascularity overall, and hypersensitive right calf/foot areas.

Discussion

Untreated compartment syndrome has serious implications, resulting in muscle and nerve necrosis, systemic acidosis, rhabdomyolysis with myoglobinuria, and subsequent renal failure and possible death [5,6]. The presented case demonstrates the severe complication of renal failure requiring hemodialysis due to acute gluteal compartment syndrome when there was a delay in seeking medical care. Fortunately, our patient’s renal function and urine output improved about one week after hemodialysis was initiated, allowing for its eventual termination. However, long-term neuromuscular deficits resulting from his apparent sciatic nerve damage due to prolonged increased compartmental pressures may be permanently present. Continued physical rehabilitation, along with cessation of recreational drug use, is paramount to ensure maximal recovery from his deficits.

A series of wick catheter measurements were utilized in diagnosing this case of acute compartmental syndrome. The patient’s gluteal compartment measurements were 62 mm Hg on three separate studies, while his diastolic blood pressure was 72. Most studies involving wick catheter measurements in diagnosing acute compartment syndrome involve traumatic tibial fractures, so practitioners must rely on extrapolation for the gluteal compartment. One-time intracompartmental pressure measurements can overestimate the rate of compartment syndrome and raise concern regarding unnecessary fasciotomies [8]. Traditional, absolute pressure readings of greater than 30 mm Hg should not be used to diagnosis acute compartment syndrome. The importance of serial measurements, along with interpreting the data in correlation with clinical observation, is key to appropriately and quickly diagnosing acute compartment syndrome.

The diagnosis of compartment syndrome should be made on the basis of sequential differential pressure measurements rather than awaiting the development of clinical signs and symptoms [7]. Practitioners who are unfamiliar with the pathophysiology of compartment syndrome often place emphasis on the presence of pulses to incorrectly rule out compartment syndrome [1]. The presented case is a prime example of an acute compartment syndrome that might have been missed due to the presence of bilateral lower extremity pulses. Treatment should include immediately relieving all external pressure on the compartment, and the limb should neither be elevated nor placed in a dependent position. Placing the limb level with the heart helps to avoid reductions in arterial inflow [9] and avoids increases in compartment pressures from dependent swelling, both of which can exacerbate limb ischemia. A keen sense by providers for diagnosing and treating compartment syndrome is a requirement for preventing severe complications, prolonged hospital stays, and even death.

Conclusions

The presented case highlights the crucial importance of early recognition and proper diagnosis by healthcare providers of acute compartment syndrome. In our case, peripheral pulses remained palpable despite severely elevated gluteal compartment pressures obtained by serial wick catheter measurements. Failure to have obtained the true diagnosis and undergo an emergent fasciotomy in a timely matter would likely have resulted in devastating consequences. Fortunately, hemodialysis was only utilized as a temporary measure in this case.