Working Diagnosis:
Acute anterior compartment syndrome of the left thigh secondary to delayed expansion of a traumatic intramuscular hematoma.

Treatment:
The patient underwent emergent fasciotomy of the left anterior thigh compartment with evacuation of approximately 200 cc of clotted hematoma and placement of an incisional wound vacuum-assisted closure (VAC) device. Postoperatively, he was allowed weightbearing as tolerated and began physical therapy focused on restoration of motion and strength.

Outcome:
Pain improved substantially following surgical decompression. Motor and sensory function remained intact throughout hospitalization. The patient regained full knee range of motion with rehabilitation and was discharged home with an incisional wound VAC. At his two-week follow-up appointment, the incision was healing appropriately without drainage or infection, and strength recovery was progressing as expected.

Author's Comments:
Acute thigh compartment syndrome is a rare but limb-threatening condition due to the relatively large volume and compliance of the thigh compartments. Most cases of compartment syndrome occur in the lower leg or forearm, making delayed thigh compartment syndrome after a sports-related quadriceps contusion particularly uncommon. This case is further distinguished by the delayed presentation, with symptoms progressing over ten days despite continued athletic participation and a strenuous workout shortly before presentation. Ongoing activity likely contributed to expansion of the intramuscular hematoma and worsening compartment pressures.

This case highlights several important learning points for sports medicine providers. First, compartment syndrome remains a clinical diagnosis and should be considered in any athlete with escalating pain following blunt extremity trauma, even when distal pulses, sensation, and motor function remain intact. The absence of neurovascular deficits does not exclude the diagnosis. Second, pain out of proportion to the apparent injury and pain with passive stretch are the most sensitive early examination findings and should prompt urgent evaluation. In this patient, severe escalating pain, a tense swollen thigh, and pain with passive knee flexion raised concern for compartment syndrome despite the delayed timeline and otherwise reassuring neurovascular examination.

Although imaging and compartment pressure measurements were useful in confirming the diagnosis, definitive treatment should not be delayed when clinical suspicion is high. Prompt fasciotomy remains the standard of care and is essential to prevent irreversible muscle necrosis, neurologic injury, permanent functional deficits, and loss of athletic participation. This case underscores the importance of maintaining a high index of suspicion for compartment syndrome in athletes with worsening symptoms after quadriceps contusion, particularly when pain becomes disproportionate to examination findings or increases with passive stretch.

Editor's Comments:
Acute compartment syndrome is a surgical emergency that may lead to irreversible tissue ischemia and necrosis without prompt recognition and treatment. This case highlights a unique diagnosis of thigh compartment syndrome which is much less common than compartment syndrome of the lower extremity and accounts for only 7% of acute compartment syndromes. A recent review of 38 adult patients with acute thigh compartment syndrome treated with fasciotomy (Rodriguez et al, 2022) found that the majority of cases were associated with a fracture (39%) and/or anticoagulation (38%). Four cases (10%) were related to sports injuries, and only one case was attributed to a traumatic hematoma in a patient with von Willebrand disease.

Considering the epidemiology and relatively low incidence in sports-related trauma, the author of this case highlights excellent points related to the critical importance of maintaining a high index of suspicion for the diagnosis of acute compartment syndrome given its limb-threatening consequences. Specifically, a clinical diagnosis of compartment syndrome must be considered in patients presenting with pain out of proportion, even in the absence of neurovascular deficits which may be late findings. Compartment syndrome can be confirmed with measurement of elevated compartment pressures greater than 20-30 mmHg (or pressures that come within 30 mmHg of a patient’s diastolic blood pressure). Once the diagnosis of compartment syndrome is suspected or confirmed, additional diagnostic testing, such as MRI, should not delay consultation and treatment as irreversible tissue damage may occur as soon as 6-8 hours from the onset of symptoms.

References:
1. Davis ML, Della Rocca GJ, Brenner M, et al. ACS TQIP Best Practices in the Management of Orthopaedic Trauma. Chicago, IL: American College of Surgeons; 2015.
2. Mortensen SJ, Vora MM, Mohamadi A, et al. Diagnostic modalities for acute compartment syndrome of the extremities: a systematic review. JAMA Surg. 2019;154(7):655-662.
3. Orthobullets. Thigh Compartment Syndrome. https://www.orthobullets.com/trauma/1063/thigh-compartment-syndrome. Accessed April 20, 2026.
4. Rodriguez J, Suneja N, von Keudell A, Zhang D. Surgical demographics of acute thigh compartment syndrome. Injury. 2022 Oct;53(10):3481-3485.

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