{
 "topic": "Compartment Syndrome",
 "slug": "compartment-syndrome",
 "category_id": 15878,
 "passage_count": 14,
 "source_chars": 12016,
 "enough_material": true,
 "references": [
  {
   "title": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "author": null,
   "pages": []
  },
  {
   "title": "Pediatric Board Study Guide",
   "author": null,
   "pages": [
    488
   ]
  },
  {
   "title": "Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: Expert Consult - Online",
   "author": null,
   "pages": [
    856
   ]
  },
  {
   "title": "Caring for the Hospitalized Child",
   "author": "Section on Hospital Medicine, American Academy of Pediatrics;Jeffrey C. Gershel;Daniel A. Rauch;",
   "pages": [
    748
   ]
  },
  {
   "title": "Cover",
   "author": "Vitalsource Download",
   "pages": [
    3226
   ]
  },
  {
   "title": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024",
   "author": null,
   "pages": [
    625
   ]
  }
 ],
 "passages": [
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "Children with compartment syndrome may present with only one associated sign or symptom, with pain being the most common presentation. In one study of compartment syndrome with tibial shaft fractures, adolescents (14 years and older) had an increased risk of compartment syndrome compared with younger children. Clinical Considerations Clinical Recognition Open fractures typically occur due to a high-energy mechanism; therefore, a complete examination to identify other potentially life-threatening injuries is imperative. A fractured extremity should be carefully examined for the presence of an open wound, potentially signifying an open fracture. However, it is not always obvious if the injury is an open fracture or if it is a laceration that does not communicate with the fracture. Operative exploration by the orthopedist may be necessary to determine this."
  },
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "Compartment syndrome develops when there is an accumulation of intracompartmental pressure resulting in obstruction of venous outflow and then increased pressure in the nonelastic compartment. If untreated, small arterioles and capillaries are eventually occluded, resulting in ischemia with irreversible muscle and neurovascular tissue damage. Compartment syndrome must be suspected with any fracture or blunt tissue injury when there is pain out of proportion to the injury or if the pain is increasing, despite analgesic administration. The patient may also complain of paresthesias and pain with passive extension. On physical examination the patient may have pallor and pulselessness of the injured extremity, although these may be late findings. Triage Considerations Children presenting with a concern for an open fracture or compartment syndrome should be evaluated immediately in the ED with urgent orthopedic consultation. Clinical Assessment"
  },
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "Compartment Syndrome. If there is concern for nerve compression or vascular insufficiency in a child with a muscle or soft tissue bleed, immediate intervention is important. Compartment syndrome is a limb-threatening event. Imaging of the affected area and consultation with orthopedics is necessary. Iliopsoas or Thigh Hemorrhage. Retroperitoneal bleeds can be life threatening and may present with lower abdominal pain. A mass is sometimes palpable deep in the pelvis, and sensation in the distribution of the femoral nerve may be diminished. Loss of the psoas shadow may be seen on an abdominal radiograph, and a hematoma may be demonstrated by ultrasonography. The hemoglobin level should be measured initially and, if bleeding persists, at regular intervals thereafter."
  },
  {
   "source": "Pediatric Board Study Guide, p. 488",
   "text": "- Radiograph will be negative ## **Compartment Syndrome** ## **Treatment** ## **Background** - Elevation of the interstitial pressure in a closed osteofascial compartment that results in microvascular compromise - Compartment syndrome should be suspected in children involved in accidents with high-energy trauma to the extremities - More common with fractures of the lower leg and forearm ## **Diagnosis** - _Tense non-compressible swelling_ of the affected compartment - Increase in the narcotic requirements to keep the child comfortable is an early sign of increased compartment pressure - Severe excruciating pain with passive stretch of the distal joints (toes or fingers) - Paresthesias, pulselessness, and paralysis are late findings, and the absence of these signs does not rule out this diagnosis - Compartment pressure can be measured using a pressure needle. Pressure more than 30 mmHg suggests that patient may have compartment syndrome ## **Treatment**"
  },
  {
   "source": "Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: Expert Consult - Online, p. 856",
   "text": "A compartment syndrome arises whenever the interstitial tissue fluid pressure exceeds the capillary perfusion pressure within a muscle compartment. In clinical practice the interstitial pressure elevation must reach approximately 35 to 45 mm Hg for this to occur. Because the enclosed fascial boundary of the involved muscle compartment is unyielding, hemorrhage or edema within it can cause interstitial pressure to rise to such levels, resulting in muscle ischemia and neurovascular compromise. Compartment syndromes are not rare in childhood and can be seen after open or closed fractures, crush injuries, or prolonged pressure on an extremity, which can occur in a comatose child who has been lying on an extremity for several hours. A displaced fracture of the proximal tibial metaphysis is the fracture most likely to be complicated by a compartment syndrome. Other fractures that are well documented to predispose to the development of this problem include supracondylar humerus fractures and displaced forearm"
  },
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "COMPARTMENT SYNDROME Current Evidence Compartment syndrome refers to vascular insufficiency caused by elevated tissue pressures that usually occurs after an injury involving hemorrhage or edema within an enclosed fascial compartment. Tight circumferential bandages or casts can also limit expansion of swollen tissues and result in elevation of tissue pressures. Fluid extravasation from intravenous or intraosseous lines, especially pressure-driven extravasation, may significantly elevate compartment pressures. Direct injury to an artery is less common as the cause of vascular insufficiency after injury but is also considered as compartment syndrome. Increased intra-abdominal pressure from various causes including intestinal obstruction and burns can cause an abdominal compartment syndrome that is immediately life-threatening due to inferior vena cava compression and reduced venous return."
  },
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "Clinical Assessment/Initial H&P The \u201cfive Ps\u201d of compartment syndrome is a mnemonic that should be replaced by the \u201cthree As.\u201d Pain alone is often the only early symptom or sign of vascular insufficiency when interventions should be started. Anxiety, Agitation, and Analgesia requirement, which are manifestations of pain in children, should provoke consideration of compartment syndrome. The astute clinician should suspect compartment syndrome and consult an orthopedic surgeon before paresthesia, pallor, paralysis, and pulselessness are present."
  },
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "Knowledge of the common pediatric injuries that are associated with compartment syndromes can raise the clinician\u2019s index of suspicion appropriately. Lower leg fractures of the tibia and/or fibula are responsible for 60% of compartment syndromes. Fractures that are open are at greater risk for the development of a compartment syndrome, perhaps because they result from higher-energy mechanisms. Displaced supracondylar fractures may injure the anterior interosseous artery and the flexor compartment of the forearm causing a compartment syndrome that leads to the classic Volkmann contracture. Though controversial, some have suggested that delayed reduction is a risk factor for compartment syndrome after supracondylar fracture. Forearm fractures may also cause compartment syndromes, affecting either the flexor or extensor musculature. Compartment syndromes may occur from crush injuries and other soft tissue trauma that does not necessarily involve a fracture. Poisonous snakebites, especially pit vipers, and deep"
  },
  {
   "source": "Caring for the Hospitalized Child, p. 748",
   "text": "## _**Compartment Syndrome**_ The signs of compartment syndrome in older patients, commonly known as the \u201c5 Ps,\u201d are pain out of proportion to the severity of injury, pallor, paresthesia, pulselessness, and paralysis. These signs can be less reliable in a child. Instead, use the \u201c3 As\u201d: anxiety, agitation, and an increasing analgesia requirement. Maintain a high index of suspicion, because not all of these signs need to be present to diagnose compartment syndrome. ## _**Fat Embolism**_ Fat embolism and respiratory distress syndrome can occur in a patient with a long bone or pelvic fracture. The risk increases if surgical repair is delayed more than 24 hours and the patient has an open fracture. Caring for the Hospitalized Child **722** ## **Treatment** ## _**Analgesia**_"
  },
  {
   "source": "Cover, p. 3226",
   "text": "A rare but devastating variant of compartment syndrome occurs in the neonate. It develops during the immediate antepartum period, but the exact etiology is unknown. Intrinsic thrombophilic mechanisms as well as extrinsic compression have both been implicated. The neonate presents in the delivery room with a swollen, paralyzed, dysvascular limb. There is typically a sentinel bullous or open lesion on the forearm ( **Fig. 214-1** ). ![](/tmp/pdf-images/pdf-3226-02.png) **FIGURE 214-1** The appearance of the forearm with a neonatal compartment syndrome. Note the sentinel lesion and the discoloration. Unrelieved ischemia resulting from compartment syndrome results in muscle necrosis, cellular breakdown, hemoglobinuria, and permanent functional loss of the limb. The only treatment that may salvage some function is emergency surgical fasciotomy. For additional details on injuries and fractures please refer to the other chapters within Section 16. ## **INFECTION**"
  },
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "If there is suspicion for compartment syndrome, compartment pressures in the injured extremity should be obtained; however, this may be difficult in an awake young child, especially if less than 5 years old. Compartment pressures >30 mm Hg have been used to diagnose compartment syndrome. Newer approaches suggest that compartment pressures should be interpreted in the context of systemic blood pressures. Compartment pressures within 30 mm Hg of either the diastolic blood pressure or the mean arterial pressure are concerning for compartment syndrome. Urgent orthopedic consultation is necessary if there is any concern for compartment syndrome, which may require treatment with fasciotomy. Disposition All children with open fractures or with concern for/diagnosis of compartment syndrome should be admitted to the hospital for ongoing orthopedic care given the high risks for infection and neuromuscular injury. MULTIPLE TRAUMA CLINICAL PEARLS AND PITFALLS"
  },
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "Clinical Assessment For open fractures, the wound should be carefully examined and considered in the context of the fracture location. With compartment syndrome, the extremity may be pale and the muscular compartments may be swollen and feel hard and tense. The pulses may be diminished or absent and the limb may have paralysis or muscle weakness. Children may present with only a single sign or symptom of compartment syndrome. Management"
  },
  {
   "source": "Pediatric Board Study Guide, p. 488",
   "text": "## **Treatment** - Once compartment syndrome is suspected, cast and splints should be removed or split immediately - The affected extremity should be elevated to the level of the heart (elevating the extremity above the level of the heart will decrease tissue perfusion) - Urgent orthopedic consult: Definitive treatment of compartment syndrome consists of wide prompt release of the affected compartments (fasciotomy) ## **Radial Head Subluxation** ## **Nursemaid Elbow (Pulled Elbow)** ## **Background** - Subluxation of the radial head from the annular ligament - Common condition in young children aged 1\u20134 years ## **Diagnosis** - A child with no obvious history of trauma will suddenly refuse to use his/her arm. - Reduction maneuvers: Supination or hyperpronation: (Fig. 13.50a, b) - Supination maneuver: One hand supports the elbow and the other hand applies axial compression at the wrist while fully supinating the forearm and then flexing the elbow (Fig. 13.50a)"
  },
  {
   "source": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024, p. 625",
   "text": "An acute extremity compartment syndrome is a surgical emergency usually associated with extremity fractures (e.g., tibia, supracondylar humerus, distal radius) but has also been noted after thermal and electric injuries, rhabdomyolysis, coagulopathies, or nephrotic syndrome. Manifestations include pain out of proportion to the injury, pain with passive stretching of the muscles, poor distal pulses, pallor, paresthesia, and weakness. In children, escalating pain not relieved by pain medications, anxiety, and agitation are additional features. If needed, compartmental pressure should be measured (normal is 8 mm Hg in adults, 10- 15 mm Hg in children). Absolute pressure \u226530 mm Hg is one indication for fasciotomy. Another indication for fasciotomy is a diastolic blood pressure minus compartment pressure <30 mm Hg. ## **Advanced Imaging**"
  }
 ]
}