Working Diagnosis:
Left quadriceps contusion and hematoma leading to compartment syndrome

Treatment:
He was admitted and underwent fasciotomy for compartment syndrome and evacuation of his hematoma in the operating room. Post-operative, he had worsening pain and bleeding. This led to another surgery, where he had re-accumulation of the hematoma, and his wound was packed and left open. After the second operation, he again had persistent bleeding and pain. Bedside exam revealed an arterial bleed deep within the muscle, and repeat labs showed a drop in his hemoglobin from 11.4 to 8.4. He was taken to the operating room for a third procedure where his fasciotomy was extended to a total of 20 cm, and a branch of the profundal artery was ligated. The next day, after remaining hemodynamically stable, with stable labs, adequate analgesia, and no excessive bleeding, he returned to the operating room for a fourth and final procedure to irrigate and close his wound. He was discharged on hospital day three with a wound vac over his closed fasciotomy site.

Outcome:
After discharge from the hospital, he remained on crutches and non-weightbearing of the left lower extremity. The wound vacuum assisted closure was successfully removed after one week, and the patient had continued on a progressive rehabilitation program. He returned to the field for individual position drills during the spring football period, however had not returned to full contact drills by that time. He also had persistent vastus medialis oblique weakness which was not recovering as expected. This raised the concern of possibly permanent nerve damage.

Author's Comments:
Compartment syndrome is not commonly seen in the thigh. This patient developed compartment syndrome due to a hematoma from a hit during football. This needs to be in the differential, as it can lead to complications such as nerve damage. Unfortunately for this patient he had an arterial bleed which contributed to his hematoma causing it to reaccumulate. This makes this case more difficult as the patient despite surgery had the reaccumulation of blood causing the prolonged compression of the nerve.

Editor's Comments:
Compartment syndrome can affect different parts of the body. It is most commonly seen in the leg. It is also seen in other areas such as the forearm, hand, foot, buttocks and thigh. It is important to keep this in the differential as this can cause irreversible muscle and nerovascular damage. Treatment consists of a fasciotomy to any of the 3 compartments (Anterior, medial, and posterior) affected.

References:
Smith, E. J., Putukian, M., & McCarty, E. C. (2022). Netter's Sports Medicine (Netter Clinical Science). In Football (3rd ed., p. 545). Elsevier.

Von Fange, TJ; Fields, KB; Grayzel, J. Last updated: Feb 24, 2021. Quadriceps muscle and tendon injuries. UpToDate.

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