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

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SECTION ONE • Fundamentals of Pediatric Fracture Care

TABLE 6-2. Compartments of the Upper Extremity

Compartments

Contents

Arm Anterior

Biceps and brachialis, brachial artery, and median nerve Triceps, ulnar nerve, and radial nerve FCR, PL, pronator teres, FCU, and FDS FDP, FPL, and pronator quadratus Anterior interosseous nerve and artery

Posterior

Forearm Volar

Superficial

Deep

Dorsal

Mobile wad Brachioradialis, ECRL, ECRB Extensor EDC, ECU, EPL, APL,

EPB, EIP, EDM, supinator, a posterior interosseous nerve

Anconeus

Anconeus b

Hand Thenar

Abductor pollicis brevis, opponens pollicis, and flexor pollicis brevis Abductor digiti minimi, flexor digiti minimi, and opponens digiti minimi

Figure 6-1. Cross-sectional anatomy of the arm is shown. The dotted line represents the plane of dissection for decompression of the anterior and posterior compartments through a medial incision. The intermus cular septum can be excised, which further decompresses both com partments. Alternatively, a straight anterior and posterior incision may be used to separately decompress the anterior and posterior compart ments. (Courtesy of Dr. M. Stevanovic.)

Hypothenar

Adductor pollicis

Adductor pollicis (two heads)

Dorsal interossei (4) Volar interossei (3)

Each separate compartments Each separate compartments

Fingers

Cleland and Grayson ligaments c

by increased compartmental pressure. Through the same inter val, the fascia overlying the pronator quadratus is also released. During the dissection, if the muscles appear pale after release of the fascia, then additional release of the epimysium of the pale muscle should be performed. For these muscles, reperfu sion injury will lead to more swelling in the muscle which will lead to further muscle injury if the epimysium is not released. Clinical evaluation at this time of the remaining tension in the dorsal forearm compartment and/or hand should be done to determine whether additional release of the extensor compart ments and hand should be added. The extensor compartments are released through a midline longitudinal dorsal incision c Not technically a compartment, but compression of the neurovascular structures by rigid Cleland and Grayson ligaments can lead to skin necrosis and/or loss of the finger. APL, abductor pollicis longus muscle; BR, brachioradialis muscle; ECRB, extensor carpi radialis brevis muscle; ECRL, extensor carpi radialis longus muscle; ECU, extensor carpi ulnaris; ED, extensor digitorum muscle; EDM, extensor digiti min imi muscle; EPB, extensor pollicis brevis muscle; EPL, extensor pollicis longus muscle; FCR, flexor carpi radialis muscle; FCU, flexor carpi ulnaris muscle; FDP, flexor digitorum profundus muscle; FDS, flexor digitorum superficialis muscle; FPL, flexor pollicis longus muscle; PL, palmaris longus muscle. a The supinator is not typically a component of extensor compartment syndrome, but decompression can be done through the brachioradialis/ECRL interval. b Not typically listed as a separate compartment, but should be assessed.

Figure 6-2. Cross-sectional anatomy of the forearm is shown. The dotted lines represent the plane of dissection for dorsal and volar com partments. The superficial flexor compartment can be released in the midline or any location, trying to avoid an incision over the radial or ulnar artery or median nerve. The deep flexor compartment is best released by opening the interval between flexor carpi ulnaris and the flexor digitorum superficialis. (Courtesy of Dr. M. Stevanovic.)