What thigh musculoskeletal (MSK) injuries require urgent surgery?

Thigh Musculoskeletal Injuries Requiring Urgent Surgery

Compartment syndrome, vascular injuries, and mangled extremities are the primary thigh musculoskeletal injuries requiring urgent surgical intervention to prevent mortality and severe morbidity.

Compartment Syndrome

Compartment syndrome of the thigh is a surgical emergency requiring immediate fasciotomy to prevent tissue necrosis, systemic complications, and potential limb loss.

• Urgent surgical decompression is necessary in most cases of deep abscesses, compartment syndrome, and virtually all necrotizing soft tissue infections 1
• Clinical findings suggesting thigh compartment syndrome include a tense, edematous thigh (present in 69.5% of cases) 2
• Time is critical - fasciotomy performed after irreversible tissue ischemia has developed can lead to severe infection, amputation, renal insufficiency, and death 2
• Compartment syndrome may develop rapidly (within 5 hours) in patients with associated arterial injuries 3
• Blast injuries are a common mechanism for thigh compartment syndrome in combat settings, with high associated mortality (23%) 4

Vascular Injuries

Vascular injuries in the thigh require urgent surgical intervention to prevent limb loss and life-threatening hemorrhage.

• Uncontrollable life-threatening hemorrhage, avulsion of vascular structures, and pulsating/expanding hematomas require immediate operative management 1
• Hemodynamically unstable patients with severe limb trauma complicated by vascular injury should undergo damage control surgery 1
• Arterial injuries often present with hemorrhage or ischemia and require prompt recognition and treatment for optimal outcomes 5
• In cases of severe renal vascular injuries without self-limiting bleeding, operative management is indicated 1
• Angiography with super-selective angioembolization may be indicated in hemodynamically stable patients with arterial contrast extravasation, pseudoaneurysms, or arteriovenous fistulas 1

Mangled Extremities

Severe thigh injuries with extensive tissue damage may require urgent surgical intervention.

• Crushed, degloved, or mangled extremities are severe injuries that result in extensive tissue damage requiring prompt surgical intervention 1
• Clinical situations favoring urgent surgical intervention include complete traumatic amputation, large loss of substance making skin coverage impossible, proven nerve section, multiple fractures with bone loss, or ischemic vascular lesions 1
• No single gravity criterion requires amputation, but damage control strategy is recommended in cases of hemorrhagic shock associated with severe limb trauma 1
• The Mangled Extremity Severity Score (MESS) alone should not dictate amputation decisions, as studies show 43.2% amputation rate in patients with MESS scores >8 1

Decision-Making Algorithm for Urgent Surgery

1. Assess hemodynamic status:

   • Unstable patients (vasopressor requirements, multiple transfusions, lactate >4 mmol/L) require immediate surgical intervention 1
   • Stable patients allow for more detailed evaluation before surgery 1

2. Evaluate for compartment syndrome:

   • Tense, edematous thigh
   • Pain out of proportion to injury
   • Pain with passive stretch
   • Paresthesias
   • Perform immediate fasciotomy if diagnosed 1, 2

3. Assess vascular status:

   • Active hemorrhage requires immediate control
   • Signs of ischemia (pallor, pulselessness, paresthesia, paralysis, poikilothermia) indicate urgent vascular repair 1
   • Consider angiography in stable patients with suspected vascular injury 1

4. Evaluate tissue viability:

   • Necrotizing soft tissue infections require urgent debridement
   • Crushed or mangled tissue may require debridement or amputation 1
   • Large areas of devitalized tissue require urgent debridement 1

Special Considerations

• Temporary stabilization with external fixators is preferred over skeletal traction when definitive osteosynthesis is not anticipated in the next 24-36 hours 1
• In patients with severe associated injuries (brain, thorax, abdomen, pelvis, spinal cord), circulatory shock, or respiratory failure, a delayed definitive osteosynthesis approach is recommended 1
• Anticoagulation therapy can increase the risk of compartment syndrome development even with minor injuries 6
• Vascular injuries may occur during orthopedic procedures due to proximity of vascular structures to bones and joints, requiring vigilance and prompt intervention 5

Pitfalls to Avoid

• Delaying fasciotomy in suspected compartment syndrome can lead to irreversible muscle necrosis, amputation, and systemic complications 2
• Relying solely on scoring systems like MESS to determine amputation versus limb salvage 1
• Failing to recognize associated vascular injuries in patients with thigh compartment syndrome 3
• Overlooking compartment syndrome in anticoagulated patients with even minor injuries 6
• Neglecting to perform frequent reassessment of patients with severe limb injuries to identify optimal timing for definitive surgery 1