Dr. KSV Rao provides an overview of compartment syndrome in children, including causes, presentation, diagnosis, and treatment. Compartment syndrome is a true orthopedic emergency caused by elevated pressure within a closed fascial space, reducing tissue perfusion and resulting in cell death. It can occur due to trauma, fractures, casts, or other systemic issues. In children, it can be harder to diagnose due to their anxiety and the non-specific early symptoms of agitation, anxiety, and increasing pain requirements. Timely fasciotomy when compartment pressures are elevated or the pressure-perfusion difference is low is crucial to avoid muscle and nerve damage.

1. compartmentsyndrome in children Dr ksvrao

2. 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

3. 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

4. Lower limb CS –femoral vein thrombosis from systemic DIC

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

6. 9-year-old with a cerebral aneurysm who developed compartment syndrome of the hand secondary to an intravenous dilantin infusion

7. B) Local trauma Tibialdiaphyseal fractures Soft tissue injury Distal radius fractures Forearm diaphyseal fractures Elbow fractures dislocation Supracondylar fractures Tibial plateau fractures Femoral diaphyseal fracture High energy injury*

8. NEONATAL COMPARTMENT SYNDROME Rare Misdiagnosied ?Hemiplegia Birth trauma and low neonatal blood pressure-probable cause

9. 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 PediatrOrthop Volume 30, Number 2 Supplement, March 2010

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

11. 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.’’

12. Number of patients with 5P’s as part of their presentation with compartment syndrome J Pediatr Orthop, Vol. 21, No. 5, 2001

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

14. Challenge in children Scared and anxious children- not ideal patients Difficult diagnosis Inexperienced staff unable to detect a patient with compartment syndrome

15. 3A s—in children Agitation, Anxiety Analgesic requirement increasing These preceed the classic presentation by several hours

16. 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

17. CS in SC fracture Risk Factors for Vascular Repair and Compartment Syndrome in the PulselessSupracondylarHumerus Fracture in Children Paul D. Choi, MD, RojehMelikian, MD,w and David L. Skaggs, MD J PediatrOrthop Volume 30, Number 1, January/February 2010 Largest series of pulselesssupracondylar fracture in literature

18. Choi et al Reviewed 1255 supracondylarhumerus fractures in children treated operatively over 12 years at one institution. They identified 33 patients (2.6%) who presented with displaced supracondylarhumerus 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 PediatrOrthop Volume 30, Number 1, January/February 2010

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21. Choi et al--- Pulselesssupracondylar 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

23. 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 cubitalfossa/soft tissue swelling

24. 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

25. 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.

26. 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.

27. Patients and treatments at high riskfor compartment syndrome Tibial tubercle avulsion -bleed in the anterior compartment! Ant tibialreccurent 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.

28. Childhood analog of a knee dislocation,

29. 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

30. 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

31. 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.

32. 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 volarcompartment of asymptomatic children treated for supracondylarhumerus fracture.

33. 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

34. 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

35. 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 tibialosteotomy, Epidural anesthesia increases local blood flow secondary to sympathetic blockade, thereby exacerbating swelling of an injured extremity.--CS

36. Kakar et al- intraoperative DBP of patients treated with tibialintramedullary 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

37. 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

38. 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 Δp=DBP–compartment pressure is less than 20 to 30 mm of hg

39. 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

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

41. 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

42. 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

43. 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) .

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

45. 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

47. 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,

48. 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

49. 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

50. 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.

52. 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

53. 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.

54. 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

55. FUTURE NIRS Effects of antioxidants Hypertonic saline administration Tissue ultrafiltration to remove fluid from comp has shown to reduce icp Hypertonic mannitolpressure in dog model

56. Thank You (1830 - 1889), was a prominent German surgeon and poet

59. 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

60. 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