This article is part of a supplement on Upper Extremity injuries published in the Journal of Pediatric Orthopaedics. The supplement is replete with pertinent articles about the upper extremity. This chosen article highlights and updates compartment syndromes in the pediatric patient. Compartment syndromes continue to go unrecognized as children are more difficult to exam than adults. In addition, children have poor conception of numbness and paresthesias. Therefore, the physician must be aware of alternative signs.
For decades, orthopaedic residents have been trained to observe the five Ps for compartment syndrome, increasing pain, paresthesias, paralysis, pallor and pulselessness. In contrast, multiple studies have demonstrated different signs in children. The three A’s are more characteristic of children developing a compartment syndrome. The three As include: increasing anxiety, agitation, and analgesic. In a series from Boston published in 2001, the increasing analgesic requirement preceded the changes in a vascular status by an average of 7 hours in pediatric patients. Early recognition of increasing analgesic will allow ample time for fasciotomy. This simple point is the highlight of this manuscript, and we teach our orthopaedic residents that 5 Ps are not applicable to the pediatric population. The three A’s are indicative of a pediatric compartment syndrome.
The manuscript also discusses specific compartment syndromes. They highlight the neonatal compartment syndrome that is seen in children shortly after birth. There is a soft tissue sore on the forearm of children, which is noted as the sentinel skin lesion. This indicates underlying soft tissue necrosis in the compartment. Emergent release is the only way to resolve the increased pressures. This is difficult to identify in the newborn infant and requires communication between the surgeon, the anesthesiologist, and the family.
The authors also discuss the increased rate of compartment syndrome in multiple fractures in the same limb. In the upper extremity, the combination of displaced distal humerus fracture and forearm fracture (a.k.a. floating elbow) is a prime setup for compartment syndrome. Studies have reported rates up to 33% for compartment syndrome in these cases. Pin fixation of both fractures is indicated with careful postoperative monitoring. Regarding forearm fractures, previous studies have indicated that multiple reduction attempts and longer operating time results in higher rates of compartment syndrome. The surgeon should make a determination about how many close reductions should be attempted prior to proceeding with open reduction. Also, increasing fluoroscopic usage is associated with rising rate of compartment syndrome.
The authors emphasize that fiberglass casts can be put on too tight. Fiberglass casts applied without stress relaxation are known to be two times tighter than those applied with plaster. Univalving or bivaling can decrease the external cast pressure 40-60%. The authors also discuss a variety of compartment pressure monitoring techniques, including new developments and noninvasive monitoring. However, the current diagnosis relies on clinical acumen and careful assessment of the three A’s in the pediatric population.