Compartment Syndrome in Children


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:fivep

  1. Pain/Swelling
  2. Pulselessness
  3. Paresthesia
  4. Pallor
  5. Paralysis

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. pressure measureIf 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.


Carrying Angle of the Elbow

The carrying angle of the elbow is the clinical measurement of the varus-valgus angulation of the arm with the elbow fully extended and the forearm fully supinated. With the arms extended at the sides and the palms facing forward, the forearm and hands are normally slightly away from the body.

axis The intersection of the axis of the upper arm and axis of the forearm defines the carrying angle. The carrying angle is greater in shorter persons compared to taller persons. The shorter the forearm bone length is, the greater the carrying angle will be. The normal carrying angle of the elbow is between 5-15°. The carrying angle is greater in women and in throwing athletes. It is difficult to assess if there is a flexion contracture of the elbow. This angle permits the forearms to clear the hips in swinging movements during walking, and is important when carrying objects.

carrying angleCubitus varus is the opposite of cubitus valgus, causing the elbow to have inward angulation towards the midline of the body. Cubitus valgus is a deformity which causes the forearm when it is fully extended to be angled away from the body in a greater degree than normal. Supracondylar fractures usually occur in children.

If the fracture is malaligned and if it heals in a malaligned position, the fracture may develop into a severe varus deformity of the elbow which decreases the carrying angle of the elbow. This decrease of the carrying angle causes the elbow to have more of an inward angulation towards the midline of the body. This creates what is called a “gunstock deformity”. The deformity is caused by fracture malunion. This is usually a cosmetic deformity with little functional limitation.leading

A fracture of the lateral condyle of the humerus can lead to:

  1. Cubitus Valgus
  2. Stretching of the ulnar nerve

If the fracture did not heal or the fracture is malaligned, the medial part of the humerus will grow and the lateral part will not grow. The forearm will drift into valgus malalignment. The carrying angle will increase (cubitus valgus) and the ulnar nerve will be stretched and may need transposition. The nonunion of the lateral condyle of the humerus may need fixation in order to stop progression of the valgus deformity. 30° of varus or valgus angulation is tolerated in fractures of the humerus without any clinical functional significance.thirty


Detecting Misleading Patients

How can you tell if a patient is misleading you?

The patient may be malingering, lying, or exaggerating about the extent of their injuries. Detecting the occasional malingering patient can be difficult. malingeringThe physician relies on the patient’s complaints in order to treat the patient. Verbal communication with the patient is important. The patient may attempt to mislead the physician for personal gain such as with workman’s compensation claims or car accidents so they can take more time off or gain more compensation.

Sometimes, patients may allege that they are experiencing a lot of pain and weakness or that they have lost their pain medication in an attempt to get more drugs. The physician may find disparity between the patient’s explanation of the injury or condition and the actual findings during the physical exam.

Overreaction to pain is another finding. The patient may exaggerate the condition and overreact during the exam. This can take the form of extreme facial expressions, sweating, or verbal responses.

Research shows that communication can be verbal or nonverbal and that it is also possible to tell if someone is lying to you based on their body language. Verbal communication accounts for only 7% of the communication. How a person sounds when they are speaking accounts for 38% of communication and body language accounts for 55% of communication. Body language plays a big role in intuition. Body language gives us a message about what the other person is thinking. It is important to interpret the patient’s body language in order to determine if they are misleading us.

Body language involves:

  • Eye contact
  • Facial expressions
  • Gestures
  • Posture and stance
  • Space relationship

Although physicians are very good at interviewing the patient for medical reasons, they may not be good at interpreting a patient’s body language. Verbal communication is important however, nonverbal communication is more important. Facial expressions and gestures can be useful for doctors when they suspect that the patient is not telling the truth. There are many experts who claim they can detect if a person is in fact lying to them.

Here are some of the observational cues if the person is lying:

  1. Hand to Face Gestures
    1. Playing around with their mouth or couch the side of their nose.
    2. They may be actually wanting to cover their mouth which comes from childhood—similar to covering the mouth to cover a lie.
    3. Playing with a shirt collar is also a cue. facegesture
    4. Rubbing the back of the neck—this gesture may be done similar to the way a mother would rub that back of a child’s neck to provide comfort to a hurt child. Questions may cause the patient discomfort and rubbing the neck gives the patient comfort. The patient may not be doing these self-comforting gestures throughout the meeting, rather, only when certain questions are being asked.
  2. Avoiding Eye Contact
    1. Occurs suddenly
    2. May signal that the patient is not telling the truthlegs and feet
  3. How the patient uses their feet and legs
    1. It is also important to take note of when the patient is seated.
    2. The patient has freedom of the use of their legs so watch for rocking or fidgeting motions with their legs in response to certain questions.
    3. The legs and feet are the furthest away for the brain and hardest to control
  4. How the patient uses their hands
    1. The patient will typically remain with the hands open when relaxed
    2. During certain questions the patient may begin to place their hands in their pockets, behind their back, or under their arm pits.hands

Look for these nonverbal signals that the patient is uncomfortable. This may suggest that the person is misleading you. It may not be difficult to notice the signs of a patient lying once you learn to recognize these cues.

Unbelievable Bacteria- Part II

Why do open fractures have increased risk for infection?

The presence of bacteria within an open wound increases the risk of colonization when hardware is used. Once the hardware is colonized, the bacteria grows rapidly. During the rapid growth phase, the bacteria secretes a polysaccharide sugar layer, called a “biofilm”, or slime layer that encases the bacteria. This biofilm provides protection to the bacteria against the body’s defenses and antibiotics.


Within the biofilm, there are channels that allow the bacteria to pass nutrients, messaging signals, and even DNA to each other. The bacteria pass on their DNA by:


  1. Transformation
  2. Transduction
  3. Conjugation

Transformation is when a bacterial cell ruptures, releasing its DNA, which is then taken in by another bacteria. Transduction occurs when DNA is transferred from one bacterium to another by a virus. Phage DNA and proteins are made and bacterial chromosomes are broken up, completing the gene transfer. The phage release themselves from the host, carrying either bacterial or phage DNA. Conjugation occurs when two bacteria attach themselves together with a sex pilus and exchange their DNA.

How does the bacteria become resistant to antibiotics?


The bacteria can alter the genes they express by as much as 50-60%. By doing this, the bacteria can produce enzymes such as beta-lactamases, which destroy certain antibiotics before they can reach their target site. They can also make Efflux pumps which expel antibacterial agents from the cell before it can reach its target site. Finally, by expressing different genes, the bacterial cell wall can be altered to no longer contain the binding site of the antibiotic agent. Because the antibiotics cannot break through the biofilm and access the bacteria, the bacterium in the biofilm can become up to a thousand times more resistant to the antibiotics by the different mechanisms previously discussed.

If there is biofilm on the hardware, what can the physician do?


The only proven treatment, is to remove the hardware and wash the wound. However, removal of the hardware is a problem if the fracture is not healed and the fixation is needed. The physician may decide to suppress the infection, leaving the hardware until the fracture has improved. Or, the physician may decide the remove the hardware and seek an alternative method for stabilizing the fracture, such as an external fixator, and then using a biological material to help heal the fracture.

These are the issues that make infection with hardware so complex!