COMPARTMENTSYNDROME IN CHILDREN

Dr ksv rao

Described by Richard von volkmann 1881

Elevated tissue pressure within a closed

fascial space

Reduces tissue perfusion – ischemia

Results in cell death - necrosis

True Orthopaedic Emergency

CAUSES

A) Systemic disorders/Atraumatic causes

Compartment pressures -from bleeding & clotting disorders

Septicemia

Animal bites

Prolonged vascular reconstruction.

Inadvertent fluid infiltration into the soft tissues from

intravenous fluids or arthroscopy

Drug infusion—Dilantin / dopamine infusion

Iatrogenic

Lower limb CS –femoral vein thrombosis from systemic DIC

Tense swollen hand and forearm, with hand held in the intrinsic minus

9-year-old with a cerebral aneurysm who developed compartment syndrome of the hand secondary to an intravenous dilantin infusion

B) Local trauma

Tibial diaphyseal fractures Soft tissue injury Distal radius fractures Forearm diaphyseal fractures Elbow fractures dislocation Supracondylar fractures Tibial plateau fractures Femoral diaphyseal fracture High energy injury*

NEONATAL COMPARTMENT SYNDROME

Rare

Misdiagnosied

?Hemiplegia

Birth trauma and low neonatal blood pressure-

probable cause

Neonatal compartment syndrome------

Ragland et al reported -24 cases of neonatal compartment

syndrome ----only 1 case was diagnosed within the first 24

hours.

A unique sign is the presence of a ‘‘sentinel skin’’ lesion-

soft tissue sore - over the forearm of the affected limb.

In retrospect it represented the damaged soft tissue necrosis

- a sign of neonatal compartment syndrome

They termed this as the ‘‘sentinel lesion ”

J Pediatr Orthop Volume 30, Number 2 Supplement, March 2010

Growth arrest in a 12 yrs old following neonatal compartmental syndrome.

5 P’s Pain -- out of proportion , rest pain, or with passive stretch pain

in the suspect compartment.

Parasthesias *may be the earliest subjective complaint due to

increased pressure on the nerve in the tight compartment

Paralysis also sign of muscle and nerve dysfunction -- difficult

to differentiate from muscle guarding as a result of pain, in the

acute setting

Pallor and pulselessness --imply arterial insufficiency ‘‘when

pulses are diminished, the damage has been done.’’

Number of patients with 5P’s as part of their presentation with compartment syndrome

J Pediatr Orthop, Vol. 21, No. 5, 2001

Number of patients presenting with one or more of the “5Ps” of vascular insufficiency: pain, pallor, paresthesia, paralysis and pulselessness.

Challenge in children

Scared and anxious children- not ideal patients

Difficult diagnosis

Inexperienced staff unable to detect a patient

with compartment syndrome

3A s—in children

Agitation,

Anxiety

Analgesic requirement increasing

These preceed the classic presentation by several hours

Boston series The increasing analgesic requirements preceded the changes in

the vascular status by an average of 7 hours in pediatric

patients.

More than 90% of patients in the Boston study reported pain,

Only 70% had been in association with another ‘P’’,

The presence of the 5 Ps indicates prolonged ischemia and

more advanced disease

CS in SC fracture Risk Factors for Vascular Repair and Compartment Syndrome in the

Pulseless Supracondylar Humerus Fracture in Children

Paul D. Choi, MD, Rojeh Melikian, MD,w and David L. Skaggs, MD

J Pediatr Orthop Volume 30, Number 1, January/February 2010

Largest series of pulseless supracondylar fracture in literature

Reviewed 1255 supracondylar humerus fractures in children

treated operatively over 12 years at one institution.

They identified 33 patients (2.6%) who presented with

displaced supracondylar humerus fractures with absent distal

pulses.

The patients were divided into 2 groups: those at presentation

whose hand was well perfused (24) or poorly perfused (9).

Choi et al J Pediatr Orthop Volume 30, Number 1, January/February 2010

Choi et al

2

Pulseless supracondylar fracture

In patients with a well-perfused hand, fracture reduction alone

was sufficient treatment in all 24 (of 24) cases,

No patients developed compartment syndrome.

Half of these patients still had an absent palpable pulse but well-

perfused hand after closed reduction, yet did well clinically.

Patients presenting with a poorly perfused hand are at high risk

for vascular repair and compartment syndrome

In just over half of patients with a poorly perfused hand (5 of 9),

fracture reduction alone was the definitive treatment

Choi et al---

What is the vascular treatment if the pulse does not return but the hand is well perfused ?

Immediate surgical exploration

to restore the patency of the brachial

artery To prevent –

-thrombus, -contusion

-long-term cold intolerance,

- claudication, & -diminished potential

for recovery after a repeat arm

threatening vascular injury .

Observation.High rate of symptomatic reocclusion and residual stenosis with early repair

Risk of Compartment Syndrome in sc fracture

Rate of CS in SC fracture - 0.1% to 0.3%.

Poorly perfused hand -higher risk for compartment syndrome.

6% of displaced supracondylar fracture with absent pulse

develop CS

Displaced type 3 SC fracture - posterolateral displacement

Ecchymosis in the cubital fossa/soft tissue swelling

Supracondylar fracture with ipsilateral extremity fracture

increases the risk-stable fixation of both is req to monitor limb

for CS

Nerve injury-ant.interosseous nerve

Immobilization of elbow in >90° of flexion -pressure in DV

compartment.

Delayed presentation (8 to 20 hrs) of compartment syndrome

in the series, --recommended close observation in the hospital

for 24 to 48 hours after the procedure

Tibial fractures & CS

Anterior compartment - highest pressure elevation

Superficial posterior compartment - lowest pressure

Pressure measures should be taken in all compartments within 5 cm

of the level of injury.(Heckman et all)

Type 1 fibres more vulnerable.

Deep peroneal nerve is quickly affected and sensation in web space

between first 2 toes may be lost.

Intramuscular pressure is lowest in anterior compartment with ankle in

dorsiflexed position; lowest in the deep posterior compartment when the

ankle is in the plantar flexed position

Ankle plantar flexion of 0° to 37° is the most protective position for

minimizing the combined risks of anterior and posterior compartment

syndromes.

May be useful in foot/calcaneum # where deep calcaneum comp

communicates with deep post comp of leg

Weiner G, Styf J, NakhostineM, Gershuni DH: Effect of ankle position and a plaster cast on intramuscular pressure in the human leg. J Bone Joint Surg Am 1994;76:1476-1481.

Patients and treatments at high riskfor compartment syndrome

Tibial tubercle avulsion -bleed in the anterior compartment!

Ant tibial reccurent artery

Open injuries and fractures associated with nerve injury –

masks clinical signs and symptoms

33% rate of compartment syndrome in patients with displaced

distal humerus and forearm fractures

Displaced multiple fractures in the same limb - high index of

suspicion.

Childhood analog of a knee dislocation,

CS in femur fracture

Elevation of the leg in 90/90 position led to hypoperfusion, ischemia, and

rebound swelling

Femur fractures treated with overhead skin traction-Bryant traction should be

avoided in obese children (less than 2 y of age).Can involve normal side

Buck traction on an elevated Bradford frames also implicated in producing

compartment syndrome of the posterior compartments.

Use of immediate spica casting in femur fractures syndrome may result from

increased traction to the limb while the cast is being applied (Mubarak et al)

90-90 cast implicated in CS and has been changed to hip spica with correct

techniques in casting

Risk in IM nailing of forearm fractures

Markers of increased risk of CS-

Longer operative time (avg op time 118 min-vrs 76 min)

intraoperative fluoroscopy.-(1.28 min vrs 0.63)

Greater trauma, including multiple attempts at reduction

Multiple passes –misses-with the intramedullary fixation

device.-avoid-opt for openreduction

Cast and CS Splitting the cast plaster cast (univalve) can decrease 40% to 60% &

release of padding may decrease 80%. pressure

Fiberglass casts applied without stretch relaxation are 2 times tighter than

those applied with plaster --- bivalving the fiberglass cast would be needed

to see similar decreases in pressure.

Casts that are applied with the stretch relaxation method are least

constrictive of fiberglass casts and therefore univalving may be sufficient as

long as the cast can be spread and held open.

Many of synthetic casts spring back to their original position after simply

cutting 1 side of the cast.

Compartment pressure monitoring

The diagnosis of compartment syndrome is a clinical one and a high

compartment pressure measurements must be viewed in light of the

clinical scenario.

In isolated lower extremity fractures without compartment

syndromes. The average compartment measure was 36mm Hg in the

injured leg versus 16mm Hg in the uninjured leg.

Pressures greater than 30mm Hg can occur in the deep volar

compartment of asymptomatic children treated for supracondylar

humerus fracture.

Compartment measures are a useful adjunct in

some cases of potential compartment syndrome in

which the clinical symptoms are contradictory and

in patients that are obtunded or under general

anesthesia.

The normal pressure in a muscle compartment is

less than 10 to 12mm Hg

No single case of compartment syndrome remained undiagnosed on taking the differential pressure of less

than 30 mm hg as the criterion for diagnosing acute compartment

syndrome.

Δp=DBP-CP if less than 30 mm of hg is CS

Regional Anesthesia And CompartmentSyndrome

Use of these modalities may mask the primary symptom of increased pain

seen in compartment syndromes.

These modalities are contraindicated after fracture fixation or in high-risk

patients such as those undergoing tibial osteotomy,

Epidural anesthesia increases local blood flow secondary to sympathetic

blockade, thereby exacerbating swelling of an injured extremity.--CS

Kakar et al- intraoperative DBP of patients treated with tibial

intramedullary nailing decreased approximately 18mm Hg

while under anesthesia.

Preoperative DBP is a good indicator of postoperative DBP

as the intraoperative DBP is significantly lower

The surgeon should consider this when deciding whether to

perform a fasciotomy or not

Treatment Of Acute CompartmentSyndrome

Initial management*

Surgical Treatment

Fasciotomy, Fasciotomy, Fasciotomy,

All compartments !!

Simultaneously planning and performing the fasciotomy, the surgeon

needs to consider and treat the inciting etiology or any other associated

pathology. -e.g. vascular bypass/temp graft,/ext fixator,/internal fixaton

When fasciotomy?

Recommended fasciotomy if the compartment pressure is greater

than 30 or 45mm Hg.

Others have recognized that a limb may be adequately perfused if the

diastolic blood pressure (DBP) is 30mm Hg greater than the

measured compartmentpressure.

Therefore, fasciotomy may be indicated if the

Δ p=DBP–compartment pressure is less than 20 to 30 mm of hg

Δp in children

Children have a low diastolic pressure and

therefore more likely to have Δp less than 30 mm

of Hg

Mean arterial pressure rather than DBP is used in

children

Δp =MAP-CP

Fasciotomy Principles Make early diagnosis Long extensile incisions Release all fascial compartments Preserve neurovascular structures Debride necrotic tissues Coverage within 7-10 days

Complications Related to Fasciotomies

Altered sensation within the margins of the wound (77%)

Dry, scaly skin (40%)/ Pruritus (33%)

Discolored wounds (30%) /Swollen limbs (25%)

Tethered scars (26%) / Recurrent ulceration (13%)

Muscle herniation (13%)

Pain related to the wound (10%)

Tethered tendons (7%)

Fitzgerald, McQueen Br J Plast Surg 2000

Delayed Fasciotomy Is it Safe? Sheridan, Matsen.JBJS 1976 infection rate of 46% and amputation rate of 21% after a

delay of 12 hours 4.5 % complications for early fasciotomies and 54% for

delayed ones

Recommendations If the CS has existed for more than 8-10 hrs, supportive

treatment of acute renal failure should be considered. Skin is left intact and late reconstructions maybe planned

How late fasciotomy-dilemma

Is presentation is too late for a fasciotomy.?

Clinical assessment of the limb helps with decision-making.

The patient with clinical evidence of compartment syndrome who has the

ability to voluntarily contract muscles within the compartment has some

viable muscle therefore

fasciotomy is indicated regardless of the delay.

(J Am. Acad. Orthop. Surg. 2005;13:436-444)

.

Prolonged Comp Synd Muscle damage Hyperkalemia, Acidosis Myoglobulinuria Acute renal failure requiring dialysis

Measurment Of Pressure

The slit catheter and side-ported needles are the most accurate

Solid state transducer intracompartment catheter-STIC

Standard 18-gauge needle is less accurate and is not

recommended. --“Build- it -yourself” technique not reliable

Stryker instrument and the arterial line monitoring devices are

most reliable methods to measure pressure

New development in noninvasive monitoring

Near-infrared spectroscopy (NIRS) measures tissue levels of

hemoglobin and myoglobin --- infrared light penetrates living tissue

& estimates tissue oxygenation by measuring the absorption of

infrared light by tissue chromophores (oxygenated and

deoxygenated hemoglobin)

Routine pulse oximetry is neither sensitive nor specific in

identifying compartment syndrome,

Pulse phase-locked loop ultrasound

a technique in which ultrasound measures fascial displacement,

which can be correlated with intramuscular pressure

Similar to direct pressure measurements of the cornea for the

detection of glaucoma -some have looked at soft tissue

hardness as a means of diagnosing compartment

Surgery Forearm compartment syndrome - a curvilinear

volar incision is used to allow release of the superficial and deep fascial compartments as well as the carpal tunnel.

Dorsal incisions may be indicated with increased

pressure in the extensor mobile wad of muscles

Leg compartment syndrome

Medial and anterolateral skin incisions -the deep posterior and superficial posterior compartments are released medially

The anterior and lateral compartments are released from the lateral incision.

Delayed primary skin closure is performed.

Split thickness skin grafting -can be performed as early as

3 days after fasciotomy.

Usually within 7 days.

VAC –used by some- negative pressure may decrease

interstitial fluid- thus improving the ability for later closure

Medico Legal Aspects OfCompartment Syndrome

In a 23-year review of the single malpractice carrier, a risk of a

malpractice claim was 0.2% per year of practice.

Decisions in favor of the patient are at a much higher rate

(56%) than those for litigation from other orthopaedic

diagnoses --- settlement in favor of the plaintiff in less than

30% of cases.

Indemnity payment for these cases was $426,000, whereas the

average orthopaedic indemnity payment is approximately

$136,000.

Take home message

Awareness of 3 A’s of CS in children-among nursing and

medical staff.---Identification of fracture-injuries /or treatments

which increases risk of CS

Most important factor contributing to an early diagnosis in

children.

Awareness of nontraumatic causes of CS and specific groups of

patients are at risk should heighten awareness of the condition

FUTURE NIRS Effects of antioxidants Hypertonic saline administration Tissue ultrafiltration to remove fluid from comp

has shown to reduce icp Hypertonic mannitolpressure in dog model

Thank You

(1830 - 1889), was a prominent German surgeon and poet

Timing of sc fr fixation The timing of surgery for a displaced supracondylar humeral fracture is

controversial. The need to perform surgery in the middle of the night for

these injuries has recently been challenged. Four retrospective studies showed no increase in complications in children for whom surgery had been delayed longer than twelve hours.

Another study showed a possible increase in the prevalence of compartment syndrome in children with a delay of more than twenty-two hours before surgery

. In our opinion, if a delay of twelve to twenty-four hours is necessary or inevitable, the outcome should not be adversely affected. However, waiting is not better. Surgery should not be delayed unless the child has normal neurovascular function.

Furthermore, surgery should not be delayed if there is excessive swelling or soft-tissue.It should be taken as first case in next day elective list

Indications for CompartmentPressure Measurement

One or more symptoms of compartment syndrome with

confounding factors (eg, neurologic injury, regional anesthesia,

undermedication)

No symptoms other than increased firmness or swelling in the

limb in an awake, alert patient receiving regional anesthesia for

postoperative pain control

Unreliable or unobtainable examination with firmness or

swelling in the injured extremity

Prolonged hypotension and a swollen extremity with equivocal

firmness

Spontaneous increase in pain in the limb after receiving

adequate pain control