Well leg compartment syndrome in trauma surgery – femoral shaft fracture treated by femoral intramedullary nailing in the hemilithotomy position: case series and review of the literature

Figures & data

Figure 1 Positioning scheme of the legs in the hemilithotomy position. (IF Brouze).

Table 1 Our review of case reports in the literature

Article, year	Fracture type	Side	Sex	Age	BMI	Type of intervention	Length	Position of the well leg	Fasciotomy type	Post-op delay ± arguments for fasciotomy	Evolution
Dugdale et al 1989^Citation3	Isolated comminuted femur fracture	L	M	20	Unknown	IM nailing	5 hours 45 minutes	Supine. Right lower extremity: abduction, hip and knee flexion of 90°. Calf suspended in a broad well-padded sling.	2 incisions 4 compartments	Unknown	Five months post-op: moderate weakness in anterior compartment, mild contractures in deep post. Compartment.
Dugdale et al 1989^Citation3	Comminuted femur and femoral neck	L	M	23	Unknown	Locked IM nail and Russel Taylor nail	6 hours	Supine. Flexion abduction, external rotation. Right calf in a well-padded stirrup splint.	2 incisions 4 compartments	In recovery room	Six months post-op: mild sensory and motor deficits in leg and foot, resolving.
Anglen and Banovetz 1994^Citation4	Comminuted, proximal femoral shaft + femoral artery injury	R	M	21	Unknown	Nail, distal screws break, exchange nailing	6 hours	Hip and knee flexed, hip abduction. Leg padded with towels and egg crate Flexoam on a holder	2 incisions 4 compartments	18–24 hours later (no information, DVT suspicion)	Well-healed skin graft on lateral incision. Active flexion/extension 10-0-35°, normal sensation on sole of foot 2 years later.
Anglen and Banovetz 1994^Citation4	Femoral shaft Fracture Winquist III (AO 32-B) + open tibia fracture Gustilo II	Unknown	M	28	Unknown	Femoral nailing, tibial debridement	6 hours 15 minutes	Knee and hip flexion >90°, hip abduction, leg held by a well-padded stirrup: canvas straps looped around foot, padded with ABD pads, no weight on calf	2 incisions 4 compartments	The next day	Four months later: well-healed skin grafts, complete loss of active ankle dorsiflexion, anesthesia on dorsum of foot. 4 months later: consolidation. Sticks and orthosis
Carlson et al 1995^Citation6	Femurs (not more)	Both	M	17	Unknown	Right, then left IM rodding	<3 hours 30 of positioning	Left first. Hip flexion 90°, abduction 40°, external rotation 40°. Knee flexion 90°. Leg holder	Not specified	16 hours after	Recovery of 4/5 strength several months after.
Carlson et al 1995^Citation6	Femurs (not more)	Both	M	18	Unknown	Similar	Similar	Similar.	Not specified	20 hours after	Peroneal function 100% loss, 100% recovered.
Adler et al 1997^Citation7	Femoral shaft (not more)	L	M	19	Unknown	IM nailing 36 hours after trauma.	5 hours 30 minutes	Hemilithotomy position. Leg in a well-padded leg holder.	2 incisions 4 compartments	Immediately post-op: pain, abnormal intracompartmental pressures	Unknown. 3 debridements before closure.
Adler et al 1997^Citation7	Non-union of femoral shaft	G	M	37	Unknown	IM nailing,debridement of non-union, bone graft	7 hours	Similar.	4 compartments	1 hour post-op: Pain + abnormal intracompartmental pressures	5 debridements, skin graft before closure.
Adler et al 1997^Citation7	Subtrochanteric hip fracture on past femoral nailing	R	M	29	Unknown	Nail removal, ORIF with reconstruction nail.	4 hours 30 minutes	Hemilithotomy. Leg on well-padded leg holder.	4 compartments	1 hour post-op: Pain + abnormal intracompartmental pressures	Chronic burning pain in his left forefoot.
Mathews et al 2001^Citation13	Open proximal femur fracture	R	F	30	36.4	Nail, nail exchange, nail exchange with plate and Ilizarov.	7 hours 30 minutes	Hip flexion 80°, abduction 20°, knee flexion 70°. Leg in a sling oFlex bias stockinette, suspension with Flexoam (pad inserts) left leg height 20– 25 cm > heart level	2 incisions 4 compartments	Extubating. Pain + abnormal intracompartmental pressures	Skin graft. Posterior compartment contractures (operated) 8 months post-op ankle motion in flexion/extension 10-0-30°, diminished sensation on plantar side of left foot.
Mathews et al 2001^Citation13	Comminuted femoral shaft fracture + left sacro-iliac dislocation	L	F	18	34.5	IM nailing	6 hours 4 hours of leg rise	Hip flexion 90°, abduction 30°, knee flexion 80°. Leg in similar sling. Right leg height 25– 30 cm > heart level.	4 compartments. 12 hours after first fasciotomy: extension of anterior fasciotomy	.6 hour post-op and 18 hours post-op	14 month later: dorsiflexion and hallux extension M3, decreased sensation on dorsum of foot.
Christodoulou et al 2002^Citation5	Gustilo II per trochanteric and shaft femur fracture	R	M	21	Unknown	IM nailing	<5 hours (with preparation)	Hemilithotomy position. Leg in Allen Stirrup supposed.	2 incisions 4 compartments	12 hours post-op. Hypoesthesia, abnormal compartment pressures	Recovery of hypoesthesia.
Christodoulou et al 2002^Citation5	Subtrochanteric femoral fracture + three malleoli ankle fracture	L	M	44	Unknown	IM nailing	3 hours + ORIF ankle after	Similar	4 compartments	3 hours post-op	1 year later: partial loss of hallux dorsiflexion + edema.
Meldrum and Lipscomb 2002^Citation8	Comminuted subtrochanteric femur + humerus and radius	L	M	22	Unknown	IM nailing(Smith and Nephew)	3 hours 15 minutes Total anesthesia 10 hours	Leg in a well-padded stirrup	4 compartments	In recovery room: pain + abnormal compartment pressures	3 years later: complete recovery.
Meldrum and Lipscomb 2002^Citation8	Comminuted subtrochanteric	R	M	23	Unknown	IM nailing(Zimmer)	3 hours 45 minutes	Leg in a padded stirrup	Not specified	Before extubating: abnormal compartment pressures	2 years later, shortening 2 cm, paraesthesia. Pain when standing for 3 hours or more.
Weber et al 2008^Citation11	Comminuted subtrochanteric + neck	L	F	49	44.8	IM nailing	2 hours 55 minutes	Hemilithotomy	Not specified	18 hours later. Pain + abnormal compartment pressures	Loss of sensitivity in peroneal superficial nerve area, weakness in foot pronation.
Noordin et al 2009^Citation9	Midshaft	R	M	35	28.8	IM femoralnailing within 20 hours after trauma	4 hours 15 minutes	Hip flexion 90°, 40° abduction, 40° external rotation. Knee flexion 90°. Leg in a well-padded calf rest (Lloyd-Davis leg holder) ankle free. Left leg height 45 cm > heart level	4 compartments 2 incisions	14 hours post-op: hypoesthesia in peroneal area and tense anterior compartment	Recovery in 24 hours, no mechanic or neurological sequelae 7 months after.
Meena et al 2014^Citation10	Subtrochanteric (AO 33-C1)	R	M	28	37	IM nailing,then dynamic condylar screw within 48 hours after trauma.	2 hours 30 minutes	Leg flexion 70°, abduction 40°, leg placed in a leg holder. Blood pressure maintained low by anesthetists.	2 incisions 4 compartments	4 hours post-op	1 year later: full recovery.

Abbreviations: BMI, body mass index; IM, intramedullary; DVT, deep vein thrombosis.

Figure 2 Göpel type support, example of which was used for our cases photography taken by the authors in the Operation room with authorization of the heads of department and the institution.

Figure 3 Well leg positioning on a fracture table: using a pillow sling.

Note: Photographs used with permission from Am J Orthop. 2014 December;43:571–573. ©2014 Frontline Medical Communications.¹⁹

Figure 4 Male sex, height, weight, and body mass index can increase external pressure to calf region using knee-crutch-type leg holder system in lithotomy position.

Note: Copyright ©2016. Dove Medical Press. Mizuno J, Takahashi T. Male sex, height, weight, and body mass index can increase external pressure to calf region using knee-crutch-type leg holder system in lithotomy position. Ther Clin Risk Manag. 2016;12:305–312.

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