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

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CHAPTER 6 • Compartment Syndrome in Children

TABLE 6-3. Compartments of the Thigh

Compartment

Contents

Anterior

Quadriceps muscle Femoral artery, vein, and nerve

Medial

Adductor muscles Obturator nerve Hamstring muscles Sciatic nerve

Posterior

A

B

(1.9%) developed compartment syndrome, significantly less than the former report. In the same study, age 14 or older, higher body mass index, comminuted tibia fractures, and ipsilateral fibula fracture were associated with compartment syndrome. 47 In another retrospective study, 50,640 patients with tibia fractures were identified, 309 of whom had com partment syndrome. The incidence of compartment syndrome was 0.6% in all tibia fractures and 5.5% in open tibia frac tures. Of note, compartment syndrome developed in 23 of 309 (7.4%) patients after discharge and was most common in nonoperatively managed tibia fractures. Age over 13 qua drupled the risk of compartment syndrome in this popula tion. 25 Treatment of tibia fractures with flexible nails has been shown to be associated with compartment syndrome. Other risk factors include comminuted fractures, weight greater than 50 kg, and a neurologic deficit. 29 Compartment syndrome is also a well-known complication following tibial osteotomies for deformity correction. In the lower leg, a one- or two-incision technique can be employed for decompressive fasciotomy of all four compart ments, including the anterior, lateral, superficial posterior, and deep posterior compartment (Table 6-4). Both one- and two- incision techniques are appropriate if adequate decompression of all compartments is performed. 27 In the two-incision tech nique, the anterolateral incision provides access to the anterior and lateral compartments. Two- (Fig. 6-10A) and one-incision techniques are illustrated here (Fig. 6-10B). The posteromedial incision must be lengthy enough to allow for decompression of the superficial posterior compartment (more proximal) and deep posterior compartment (more distal). The soleus origin should be detached from the medial aspect of the tibia. The long lateral incision typically extends 3 to 5 cm within either end of the fibula. Identification of the septum between anterior and lateral compartments allows access to these compartments. Next, by elevating the lateral compartment musculature, the posterior intermuscular septum is visualized and access to the superficial and deep posterior compartments is possible. FOOT Foot compartment syndrome in children is rare and usually caused by crush injuries, such as a car tire running over the foot. It is associated with Lisfranc fracture–dislocations and

C

D

Figure 6-7. A, B: Dorsal incisions for fasciotomy of the hand and der motomies of the fingers. C, D: Volar incisions for release of the thenar and hypothenar compartments, carpal tunnel release, and dermotomy of the thumb. (Courtesy of Dr. M. Stevanovic.)

LOWER EXTREMITY

THIGH Compartment syndrome involving the thigh is rare but has been reported in the pediatric population after blunt trauma, external compression with antishock trousers, and vascular injury with or without fracture of the femur. Children with femoral shaft fractures treated by skin or skeletal traction may also be at risk for compartment syndrome of the thigh. The thigh has three compartments; anterior, medial, and posterior (Table 6-3). A long single lateral incision on the thigh can adequately decompress the anterior and posterior compart ments (Fig. 6-9). Occasionally, a medial adductor incision is required as well. 35 LEG The most common presentation of compartment syndrome in children involves the lower leg following a tibia and/or fib ula fracture. 11,12 A retrospective review over 13 years identi fied 1,407 patients with tibial fractures. Of these patients, 160 (11%) developed compartment syndrome. In another retro spective review of 517 tibial shaft fractures, only 10 fractures