- Compartment syndrome is one of the few orthopaedic emergencies
- Children with supracondylar humerus fractures, forearm fractures, and tibia fractures are at increased risk and should be monitored closely
- Agitation, anxiety, and an increase in analgesic needs may be the first signs of compartment syndrome in children
- Compartment syndrome is a clinical diagnosis and compartment measurements should only be performed in an obtunded patient or when the diagnosis is not clear
- With prompt diagnosis and treatment, good long term clinical results can be expected
Description:Compartment syndrome is an orthopedic emergency. Elevated compartment pressure decreases perfusion, causing muscle necrosis and nerve ischemia. Prolonged ischemia can result in irreversible damage to muscles, nerves, and the skin. Compartment syndrome is a leading cause of medical malpractice lawsuits, with an unusually high percentage settled for the plaintiff (Bhattacharyya, 2004; Prasarn, 2009). Identifying high-risk patients and prompt diagnosis and treatment are critical. Diagnosis can be particularly difficult in young children, who may have associated anxiety, inability, or unwillingness to cooperate with an exam. This inability to communicate effectively can make timely diagnosis challenging. Additionally, patients may be admitted to general pediatric floors, whose staff may not be trained to identify patients with increased intra-compartmental pressures. Physicians taking care of children should be aware of the unique features of compartment syndrome in children and be able to identify patients at risk who will benefit from close monitoring.
Epidemiology:Compartment syndrome may occur in any area where the skeletal muscle is surrounded by a layer of fascia. It occurs most commonly in the leg, forearm, hand, and foot.
Clinical Findings:Most orthopedic surgeons and residents understand the "5 Ps" of compartment syndrome (pain, paresthesia, paralysis, pallor, and pulselessness). Pain out of proportion and pain with passive stretch are usually the first signs of increased intra-compartmental pressure in adults. However, examining an anxious frightened young child for pain with passive stretch can be very difficult and quantifying the amount of pain is not reliable in young children who may not be able to communicate effectively. In a report of 33 children with compartment syndrome the 5 Ps were found to be relatively unreliable for diagnosis of compartment syndrome in children (Bae, 2001). They found that increasing analgesic requirement was documented on average 7.3 hours before a change in the vascular status and was a more sensitive indicator of compartment syndrome in children than the traditional 5 Ps. Children at risk for compartment syndrome should be closely monitored for the "3 As": increasing anxiety, agitation, and analgesic requirement (Noonan, 2010). Nursing documentation of the patient’s analgesic use can be helpful to make an early diagnosis. Injudicious use of regional anesthesia may mask the primary symptom (pain) of compartment syndrome (Mubarak, 1997; Price, 1996). Therefore, use of regional anesthetic techniques for patients at high risk for compartment syndrome should be discouraged. Although compartment syndrome is a clinical diagnosis, measurement of compartment pressure can be helpful in certain clinical scenarios. Measuring compartment pressure in an obtunded child or a child with a communication disability can help confirm or rule out this diagnosis.
Normal compartment pressures in children are higher than normal pressures in adults. Staudt et al measured pressure in four lower leg compartments in 20 healthy children and 20 healthy adults (Staudt, 2008). On average pressures in 4 compartments varied between 13.3 mm Hg and 16.6 mm Hg in children and between 5.2 mm Hg and 9.7 mm Hg in adults. Compartment pressures decrease with increasing distance from fracture site, hence measurements should be taken within 5 cm of the fracture site to ensure accuracy (Heckman, 1994).
The pressure threshold that mandates fasciotomy is debatable. Absolute pressures of 30-45 mmHg have been suggested as indications. Calculating the diastolic blood pressure minus the compartment pressure as greater than 30 mmHg (?P) has also been recommended by several authors (Hargens, 1981; Heppenstall, 1988; McQueen, 1996). Because normal compartment pressures are higher in children, these values cannot be used as reliable standards in children. Direct measurement of intracompartmental pressure using a needle and catheter is invasive and can be difficult in children. Near infrared spectroscopy is a noninvasive method that has potential utility to diagnose increased compartment pressures (Shuler, 2010; Tobias, 2007). This method uses differential light absorption properties of oxygenated hemoglobin to measure tissue ischemia, similar to the method used in pulse oximeter. In contrast to pulse oximeter, near infrared spectroscopy is able to sample deeper tissue (3 cm below the skin level). Shuler et al reported on near infrared spectroscopy findings of fourteen adult patients with acute compartment syndrome. They found that lower tissue oxygenation levels correlated with increased intra-compartmental pressures but were not able to define a cutoff value for which near infrared spectroscopy measurements would indicate significant tissue ischemia. Use of this method to diagnose compartment syndrome in children has been reported (Tobias, 2007).
Compartment syndrome remains a clinical diagnosis. Clinicians should monitor high-risk patients and closely monitor their analgesic use. Compartment measurements should be interpreted with caution, as the cut off values may be different in children than adults. The literature fails to support treatment of compartment syndrome based solely on compartment pressure measurements.
Imaging Studies:Radiographs of the effected extremity are routinely obtained when evaluating fractures, but do not play a specific role in the diagnosis of elevated compartment pressures. They may be useful to plan the site of compartment measurement.
Treatment:When compartment syndrome is suspected, circumferential dressings should be split and casts should be bi-valved. If the clinical diagnosis of compartment syndrome is made, emergent fasciotomy and decompression is indicated. Treatment of the etiology of compartment syndrome should also be kept in mind while planning the fasciotomy. Treatment of clotting deficiencies in cases caused by excessive bleeding, fracture fixation, and vascular repair may be indicated while performing the fasciotomy and decompression. In the forearm, a volar incision is used to decompress the superficial and deep compartments as well as the carpal tunnel. Dorsal decompression may be needed if the mobile wad and dorsal compartments are involved. In the leg, all four compartments (anterior, lateral, superficial, and deep posterior) should be fully decompressed. This can be achieved with either a two incision (medial and anterolateral) or one incision (lateral) technique. Delayed primary skin closure and split thickness skin grafting are commonly used for closure. Vacuum assisted closure can be used prior to final closure, and may minimize the need for skin grafting (Yang, 2006). ?
Flynn et al reported on the outcome of forty-three cases of acute compartment syndrome of the leg in children from two pediatric trauma centers (Flynn, 2011). The average time from injury to fasciotomy was 20.5 hours (3.9 to 118 hours). Functional outcome was excellent at the time of follow up in forty-one patients. The two patients that lost function had their fasciotomies performed more than 80 hours after their injuries. Despite a long period from injury to surgery in many cases, excellent results were achieved with fasciotomy in most patients. Bae et al reported the outcomes of 33 children with compartment syndrome of upper and lower extremity treated with fasciotomies. They reported that full functional recovery was achieved in 30 of 33 cases (91%) by an average of 2.5 months following surgery (Bae, 2001).
Complications:A missed compartment syndrome can have devastating complications such as chronic pain, irreversible muscle and nerve damage, fixed contractures, and the possible need for amputation. The best method for avoiding complications is to maintain a high level of suspicion for compartment syndrome and to intervene early.
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