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

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SECTION ONE • Fundamentals of Pediatric Fracture Care

long-term casting for long flexor tightness. 52 Despite this, good outcomes have been demonstrated even with delayed diagnosis of compartment syndrome, and authors postulate that the poten tial for recovery of muscle function may be greater in a child than in an adult. 18 This is consistent with the increased potential for recovery observed from other types of injuries in children, such as fractures, traumatic brain injuries, and articular cartilage injuries. Full recovery has been reported following compartment syndrome of the lower leg in children even after delayed pre sentation. 8 Good results may be possible in children even when fasciotomy is performed as late as 72 hours after the injury. 11 A multicenter study spanning 15 years showed that compartment syndrome in infants and toddlers is often delayed greater than 24 hours. Interestingly, even when fasciotomy is delayed by 48 to 72 hours, functional outcomes are excellent in most patients. 6 This should not encourage delay in treatment of compartment syndrome but rather demonstrate that some pediatric patients may still have good outcomes with unintentional delay. Children may have a delayed development rather than delayed diagnosis of compartment syndrome after the initial injury. Clini cians may diagnose and treat this late-developing compartment syndrome acutely, which may result in good outcomes noted in studies. This is why it is imperative to continuously monitor children at risk for developing compartment syndrome. If mus cle ischemia persists for longer than 6 to 8 hours, children are at risk for functional muscle loss, contracture, neurologic deficit (both motor and sensory distal to the level of injury), cosmetic deformity, growth arrest, and infection. Less commonly, loss of limb, rhabdomyolysis, multiorgan system failure, and death can

be seen, especially in the setting of crush injury with severe large-volume muscle necrosis. Delayed or missed diagnosis of compartment syndrome is one of the most common causes of successful litigation against medical professionals in North America. 4 Of 66 closed cases involving compartment syndrome, 73% (48/66) were ruled in favor of the patient, with an average payment of $574,680. 22 Patients who develop Volkmann contracture of the upper extremity during childhood may have a permanently shortened extremity thereafter. After limb ischemia, muscles are generally more affected than bone, and thus muscles grow at a slower rate than the bone, which may lead to relative tightening of the mus cles. Splinting the extremity in the functional position until age 18 may help mitigate contractures. Tendon lengthening alone often results in recurrence of contracture. Substantial improve ments in hand function are noted in patients who undergo functional free muscle transfer. Finally, in patients who have sufficient remaining muscle, procedures that combine infarct excision, tenolysis, neurolysis, and tendon transfer when necessary produce good hand func tion. 46 Improvement in sensory function in conjunction with neurolysis has been noted. In our experience, mild and mod erate contractures can have significant functional improvement following flexor muscle slide and nerve reconstruction when indicated. Normal function is not anticipated, but a hand with protective sensation and functional grasp can often be achieved. Functional free muscle transfers can also restore gross grasp and have a much better outcome in patients with good intrinsic function. This article examines 36 cases of compartment syndrome in children over 6 years at one institution. In this cohort, 75% of children who developed compartment syndrome had fractures. The authors demonstrated that previously used indicators of compartment syndrome, such as pain, pallor, paresthesias, etc., were not reliable. Increasing analgesia requirement was a more reliable predictor of compartment syndrome in the children studied. This is a retrospective review of 155 patients with chronic exertional compartment syndrome. Chronic exertional compartment syndrome was found most often in adolescent female running athletes. Anterior and lateral release as opposed to four-compartment release resulted in a recurrence in 18.8%. This article distinguishes the diagnosis of compartment syndrome in infants and toddlers from compartment syndrome in older children. Fifteen infants and toddlers who developed compartment syndrome were studied. In infants and toddlers, diagnosis was delayed compared to older children (>24 hours after injury), but regardless, outcomes were generally good even when fasciotomy was not performed for 48 to 72 hours after injury. This article examines 43 cases of compartment syndrome of the leg in children. These children had an overall delay in the time between injury and fasciotomy. The authors raise awareness for late presentation and late development of compartment syndrome of the leg in children and encourage monitoring of compartments in the days following injury. Annotation

Annotated References Reference

Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop. 2001;21(5):680–688.

Beck JJ, Tepolt FA, Miller PE, et al. Surgical treatment of chronic exertional compartment syndrome in pediatric patients. Am J Sports Med. 2016;44(10):2644–2650.

Broom A, Schur MD, Arkader A, et al. Compartment syndrome in infants and toddlers. J Child Orthop. 2016;10(5):453–460.

Flynn JM, Bashyal RK, Yeger-McKeever M, et al. Acute traumatic compartment syndrome of the leg in children: diagnosis and outcome. J Bone Joint Surg Am. 2011;93(10):937–941.