Gluteal Compartment Syndrome, An Uncommon but High Morbidity Cause
of Lower Extremity Weakness and Pain: A Case Report
Priyan Perera, MD and Dennis Keane, MD
Marianjoy Rehabilitation Hospital, Wheaton, Illinois
Abstract
Diagnosis / Treatment
Methods / Results
Case Diagnosis: Lower extremity weakness and pain secondary to nontraumatic gluteal
compartment syndrome.
Diagnosis: Physical examination includes severe buttock pain at rest associated with painful
movement of the hip. Bruising, paresthesias and tense swelling of the buttocks may also be seen.
High enough pressures can cause ischemic changes in the sciatic nerve, resulting in sciatic nerve
palsy.
• The six symptoms (6 P’s) of compartment syndrome are Pain, Paresthesias, Pallor, Paralysis, Pulselessness, and Pressure. Pain, out of proportion to injury, is the most consistent symptom (Figure 2).
• Compartment syndrome is largely a diagnosis based on clinical findings
and history. A CT or MRI of the affected area could reveal swelling of the
muscles and overlying subcutaneous tissues (Figure 3).
• There may be myoglobinuria or an associated CPK concentration of
1000-5000 U/mL or greater. The standard for diagnosis, however, is the
measurement of compartment pressures. Pressures of ≥30 mm Hg are
considered suggestive of a compartment syndrome (Figure 4).
Methods: With physical therapy, our patient underwent gentle range of motion exercises starting
the day immediately following surgery to prevent contractures. Particular attention was paid to
strengthening affected muscles as well as gait training. An assistive device was used for gait with
progressive weight bearing as tolerated. Deficits in activities of daily living were addressed with
occupational therapy. Given our patient’s history of depression, psychological counseling was also
provided.
Results: Post-fasciotomy, the patient’s swelling, pain and neurological symptoms quickly resolved.
By discharge, she had regained most of her baseline range of motion, strength, balance and level of
functioning.
Case Description: This is a 49-year-old female with a history of diabetic neuropathy who
presented to the emergency department with acute left lower extremity weakness associated with increased numbness and pain upon waking up on the floor after an unclear
amount of time. Based on imaging, laboratory results and clinical history, the diagnosis of
compartment syndrome of the left gluteal compartment was made in a timely fashion and
the patient underwent a fasciotomy of the left gluteal compartment. With time and a
comprehensive postoperative rehabilitation program, the patient regained most of her
baseline strength and independent function.
Discussion: Gluteal compartment syndrome may be a complication of prolonged immobilization often associated with alcohol intoxication, drug overdose, improper surgical positioning, and trauma. Early diagnosis can be difficult as patients often times have poor
physical signs due to altered mental status, an unknown mechanism of injury and even
preserved peripheral pulses. Affected patients are at high risk for long term neurologic
impairment from nerve compression, as well as multiple medical complications including
rhabdomyolysis.
Conclusions: This case study illustrates how a timely diagnosis of gluteal compartment
syndrome can result in effective treatment and recovery. The occurrence of compartment
syndrome in the limbs is well documented. The incidence in the gluteal region, however,
is exceptionally rare. Due to the high risk of long term neurologic impairment, considering
this syndrome in one’s differential diagnosis is critical. This case study will provide an
overview of this unique syndrome as well as how to manage it from a rehabilitation
perspective.
Treatment: The only treatment of acute compartment syndrome is
fasciotomy (Figure 5).
• Hyperbaric oxygen may be considered as an adjunct treatment after
surgery to promote healing.
• Treatment should be directed at the
underlying cause and associated
medical compllications such as renal
failure due to rhabdomyloysis.
Figure 2. Algorithm of management
for suspected compartment syndrome 3
Introduction
Figure 3. CT scan example of pelvis
showing massive edema of left gluteus
maximus and gluteus medius/minimus 4
Thick layers of tissue, called fascia, separate groups of muscles
from each other. Inside each layer of fascia is a confined space,
called a compartment. The compartment includes the muscle
tissue, nerves, and blood vessels. Fascia does not expand. Any
swelling in a compartment will lead to increased pressure, which
will press on the muscles, blood vessels, and nerves. If this
pressure is high enough, blood flow to the compartment will be
blocked (Figure 1). If the pressure is not relieved in time, complications such as tissue necrosis, nerve damage, rhabdomyolysis and organ failure may occur, which could prove fatal.2
Figure 1. Illustration of increased
intra-compartmental pressure seen
in compartment syndrome1
Gluteal compartment syndrome is often a complication of
prolonged immobilization; often associated with alcohol intoxication, drug overdose, and improper surgical positioning. Trauma
and hematoma are rare, but possible, causes as well.
Discussion/Conclusion
The focus of a rehabilitation program should be on the strengthening of affected muscles and range
of motion exercises in addition to balance and gait training.
• Precautions should be in place to protect the surgical sites.
• Any activity which may increase swelling or increase friction over those sites should be avoided.
• Strenuous exercises should also be delayed until the wound is fully healed. Gentle range of motion exercises, however, should begin as soon as possible following surgery.
• Post-fasciotomy, marginally viable tissues do not always immediately resolve, particularly in the
presence of hypotension.
• Vitals should be monitored regularly and any concern over wound healing should warrant prompt
notification of the surgeon and possible wound care consult. Blood labs should also be monitored, especially with a history of rhabdomyolysis or organ failure.
• Psychological evaluation and counseling should also be considered if there is a prior psychiatric
history or history of substance abuse.
• Of special importance is uncovering the reason for the original injury and ensuring the patient has
the appropriate interventions put in place to help prevent a similar event in the future.
Conclusion: An early diagnosis of gluteal compartment syndrome and prompt surgical referral for
fasciotomy is key to preventing irreversible muscle and nerve injury, as well as fatal complications.
A comprehensive rehabilitation program is effective in helping patients to achieve optimal functional
outcome post- fasciotomy.
References
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Figure 4. Illustration of measurement of
gluteal compartment pressures using an
intra-compartmental pressure monitor 5
Figure 5: Illustration of the effects of fasciotomy 2
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