Rockwood, Green, and Wilkins' Fractures, 10e Package

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Compartment Syndrome in Children Haleh Badkoobehi, John M. Flynn, and Milan V. Stevanovic

DIAGNOSIS

INTRODUCTION 82 DIAGNOSIS 82 CLASSIFICATION 84 Compartment Syndrome 84

A variety of injuries and medical conditions, including frac tures, external compression by tight dressings or casts, excessive flexion in a long-arm cast, elective orthopaedic procedures such as osteotomies, soft tissue injuries, burn eschar, animal and insect bites, intravenous (IV) infiltration, antishock garments, infection (group B Streptococcus ), and bleeding disorders can lead to compartment syndrome and can involve the forearm, hand, thigh, leg, and foot (Table 6-1). The most common cause of compartment syndrome is trauma, motor vehicle accidents, falls, and sports. 12,19 Similar to adults, compartment syndrome is up to four times more prevalent in boys than in girls. 2 The pathophysiology of compartment syndrome is increased pressure in a noncompliant compartment from fluid, which then occludes microvasculature of the compartment. This occlusion reduces or blocks oxygen delivery to tissues and can lead to ischemic necrosis. There is currently no gold standard diagnostic tool for compart ment syndrome, so clinical judgment is paramount. The diagnosis of compartment syndrome can be made by measuring the absolute pressure or the differential pressure of a compartment. The abso lute pressure for diagnosis of compartment syndrome is generally accepted to be a pressure of 30 mm Hg or higher in the affected compartment. Alternatively, delta pressure can be diagnostic. Dif ferential pressure, or “delta pressure” is the absolute pressure of the compartment minus the diastolic blood pressure. The delta pressure is diagnostic of compartment syndrome if it is less than 30 mm Hg. Early diagnosis of compartment syndrome may be bet ter predicted when using delta pressure over absolute pressure. 28 Pressure thresholds for diagnosis of compartment syndrome are controversial, as pressure is an indirect measure of oxygenation and can be variable depending on the operator and device used. A Federal Drug Administration (FDA) Investigational Devise Exemption study found that near-infrared spectroscopy is a noninvasive compartment syndrome monitor that reliably mea sures oxygenation in at-risk tissues. In this FDA study, contin uous near-infrared spectroscopy monitoring was performed on patients’ injured and uninjured limbs for control. A difference in perfusion between the injured and control limb was diag nostic of ischemic insult to the injured limb. Although near- infrared spectroscopy shows promise in diagnosing compartment

Impending Compartment Syndrome 84 Fracture Compartment Syndrome 84 Nonfracture Compartment Syndrome 84 Exercise-Induced or Exertional Compartment Syndrome 84 Neonatal Compartment Syndrome 84 TREATMENT 84 UPPER EXTREMITY 85 Arm 85 Forearm 85 Hand 87

Postoperative Care 87 LOWER EXTREMITY 89 Thigh 89

Leg 89 Foot 89 ESTABLISHED CONTRACTURE (VOLKMANN CONTRACTURE) 93 OUTCOMES 93

INTRODUCTION

Compartment syndrome in children is caused by sustained increased pressures within an osteofascial compartment result ing in circulatory compromise, ischemia, and ultimately tissue death. Acute compartment syndrome is rapidly progressive and is a surgical emergency. The importance of timely diagnosis and surgical intervention is critical to optimize clinical outcomes. Sometimes, compartment syndrome may have progressed before surgical intervention, in which case the surgeon will need to take care of compartment syndrome sequelae. Failure to address compartment syndrome in an expeditious manner can lead to permanent disability in the affected limb. There is also chronic compartment syndrome, or exertional compartment syndrome, which is triggered by activity and is reversible.

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