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

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CHAPTER 6 • Compartment Syndrome in Children

Anterior (Quadriceps) Medial (Adductor) Posterior (Hamstrings)

Femoral artery, vein, and nerve Medial intermuscular septum

Figure 6-9. Cross-sectional anatomy of the thigh. Note the anterior (quadriceps), posterior (hamstrings), and medial (adductor) compart ments. Entry sites for compartment pressure measurements should take into consideration the relationship between the intermuscular septa and the neurovascular structures of each compart ment. (Modified with permission from Schwartz JT, et al. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am . 1989;71(3):392–400.)

Profunda femoris artery and vein

Sciatic nerve

Posterior intermuscular septum

Lateral intermuscular septum

has been reported with fractures of the metatarsals and pha langes but may occur in the absence of a fracture. 40 There are also reports of compartment syndrome occurring following IV extravasation and with hemangioma of the foot. 49 The foot has nine compartments—the interosseous (four), adductor, central (two), medial, and lateral (Table 6-5). A dorsal approach through two longitudinal incisions centered over the second and fourth metatarsals allows for adequate decompres sion of all nine compartments, though many authors recom mend a third incision for the medial compartment (Fig. 6-11). In a systematic review of pediatric foot compartment syn drome spanning 12 years, 62 patients aged 7 months to

18 years with foot compartment syndrome were reported on and all patients had fasciotomies. 49 There is a controversial trend toward not performing fasciotomies in adult foot com partment syndrome because the main complication associated with untreated adult compartment syndrome, that is, contrac tures leading to hammertoes, is viewed as less morbid than potential sequelae of performing fasciotomies. While this prac tice may apply to management of foot compartment syndrome in skeletally mature adolescents, it may not be appropriate in children with significant growth remaining, as sustained com partment pressures may cause physeal arrest. There are also case reports of fluid extravasation in the ankle causing growth arrest. Authors speculate that this could be due to compression of the perichondrial vessels and damage to the perichondrium, which leads to a bar formation, or from a physeal tether formed by scarring of soft tissue. 48 Given the limited data available, a low threshold for fasciotomies should be maintained especially in children with significant growth remaining, as long-term functional issues may develop if not treated. 49

TABLE 6-4. Compartments of the Lower Leg

Compartment

Contents

Anterior

Tibialis anterior Extensor digitorum longus Extensor hallucis longus Peroneus tertius Deep peroneal (anterior tibial) vessels and nerve

TABLE 6-5. Compartments of the Foot

Compartments

Contents

Lateral

Peroneus longus Peroneus brevis Superficial peroneal nerve

Interosseous (4)

Interosseous muscles Digital nerves

Adductor

Adductor hallucis

Superficial posterior

Gastrocnemius Soleus Plantaris Sural nerve

Central (superficial)

Flexor digitorum brevis

Central (deep [or calcaneal])

Quadratus plantae

Medial

Abductor hallucis brevis Flexor hallucis brevis Flexor digiti minimi Abductor digiti minimi

Deep posterior Tibialis posterior

Flexor digitorum longus Flexor hallucis longus Posterior tibial nerve

Lateral