Compartment Syndrome in children can go unrecognized due to how difficult it can be to examine a child. Children have a poor perception of numbness and paresthesia and they tend to cry from injuries or fear. The actual amount of pain that a child feels cannot be estimated. It can also be challenging to remove splints or dressings in order to examine a child. In adults, well established compartment syndrome is historically defined by the 5 P’s:
These 5 P’s occur in established compartment syndrome and when these findings are present it is usually too late. These findings are considered late presentation. If the pressure is not released within 6-8 hours from its onset, there is irreversible damage to the muscles. Note for the diagnosis of impending Compartment Syndrome: it is better to diagnose compartment syndrome when it is impending rather than when it is established. The majority of clinicians will depend on a high index of suspicion supplemented by the clinical diagnosis and pressure measurements. Usually the clinician’s findings of impending Compartment Syndrome are—pain greater than after surgery or injury, tense swelling, and pain with passive stretch. If compartment syndrome is suspected, measure the compartment pressure if you can. If the compartment pressure is greater than 30mHg (absolute measurement), or within 30mmHg of the diastolic pressure, then an immediate fasciotomy should be performed. These clinical findings are different in children and physicians are usually not familiar with how compartment syndrome presents itself in children.
Clinical findings in children include:
- Increased pain with an increase in pain medication
- Increased agitation
- Increased anxiety of the child, parents, and nurses
For example, if a doctor goes on the floor and finds the nurses are with the parents in the room of the child and the child is in pain and everyone else is quiet, then there is a problem. The doctor should begin with removing the dressing and checking the extremity. Bivalving the cast will decrease the pressure significantly. When in doubt, measure the pressure. Objective findings, such as measuring the pressure, may be necessary to exclude the presence of compartment syndrome in children. The doctor may rely on his clinical judgment alone to diagnose compartment syndrome and perform a fasciotomy. However, the doctor should not rely on their clinical judgment alone to exclude compartment syndrome, especially if the patient has other findings of compartment syndrome.
Areas of concern for the development of compartment syndrome in children are: high energy fractures, multiple fractures in the same extremity (such as: floating elbow), multiple closed reductions, and/or the use of a fibroblast cast—which can be two times tighter than plaster. It is important to fix the fracture and provide post-operative monitoring with a possible delay in feeding the patient. A delay in diagnosis may lead to a poor outcome.
The use of an ACell can help with skin graft regeneration and may be used in an outpatient basis to cover the defect. The use of a VAC is always helpful.