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Compartment Syndrome: A Lurking Enemy

April 16, 2024

Acute compartment syndrome (ACS) is one of the sneakiest conditions in pediatric orthopedic practice. When you realize the patient suffers from compartment syndrome, immediate intervention is vital, as delayed recognition can lead to challenges. As described by Drs Shahrestani, Smart, Mesa, and Martin in April’s Pediatrics in Review In Brief article, "Compartment Syndrome in the Pediatric Patient" (10.1542/pir.2022-005562), ACS starts when the pressure inside a limb exceeds the pressures viable to blood vessels, restricting blood flow and causing perfusion problems in muscles and nerve tissues. Various factors, including vascular issues, infection, trauma, burns, animal bites, or systemic disorders, can trigger this pressure surge. This disruption of flow within blood vessels can lead to permanent damage, limb amputation, or even death. As clinicians, our radar must always consider the possibility of compartment syndrome, given its disastrous implications.

There are a few questions we have to ask: Do we know how to recognize the early clinical signs and symptoms? How do we promptly treat ACS? How do we prevent ACS? What is normal regular monitoring and follow-up?

ACS is suspected when a patient displays the "5 P" clinical signs: Pain, Pallor, Paresthesia, Pulselessness, and Paralysis. However, these signs often surface at a late stage. Therefore, “3 A’s” have been identified as a tool for early identification: Anxiety, Agitation, and Analgesia. Most importantly, an increasing need for analgesia and pain relief should raise awareness of ACS due to pain disproportionate to the injury. Early diagnosis is crucial, as irreversible damage can start within just 4 hours, with ischemia developing within 8 hours.

Once we suspect ACS, the first step is quickly getting a consultation from a general or orthopedic surgeon. Checking compartment pressure is a hospital procedure performed by a surgeon and is the best way to diagnose and monitor the condition. Normally, the pediatric normative values for resting compartment pressure are 13 to 16 mm Hg; variations exist based on limb and underlying health issues. To adjust for this variance, we look at the difference between the patient's diastolic blood pressure and intracompartment pressure. If this difference is 30 mm Hg or less, it's time for an emergency fasciotomy. Usually, all compartments in the affected limb are released during the decompression fasciotomy. The incisions are left open and treated with dressings or a vacuum-assisted device. After surgery, it's important to take care of the wound, reexamining it every 24 to 72 hours until no further necrotic tissue is seen. New treatments such as endoscopy-assisted compartment release have helped reduce stiffness, contractures, and the need for skin grafts and have reduced rates of complications.

In practice as a pediatric orthopedic surgeon, Dr Ramirez-Lluch developed a daily protocol to minimize and prevent the risk of compartment syndrome in his patients:

  1. Inspect the tape used to secure the IV to ensure it doesn't constrict the limb like a tourniquet.
  2. Ensure that the ID bracelet doesn’t create undue pressure, causing constriction, and assess that the ID bracelet is not placed on the same limb as the IV.
  3. Carefully assess bandages to prevent excessive tightness.
  4. Encourage the family and patient to maintain the limb elevated above heart level.
  5. In cases of fracture reduction, opt against the immediate application of a circular cast.
  6. Following limb surgery, avoid using a circular cast.
  7. Provide comprehensive guidance to the family to monitor potential changes in the patient's condition.
  8. Educate nurses and orthopedic technicians to recognize symptoms and signs indicative of compartment syndrome.

It's crucial to keep educating about this sneaky enemy. Let’s continue raising awareness about ACS, ensuring prompt interventions and reducing long-term repercussions. 

(Written in coordination with Norman Ramirez-Lluch, MD, Editorial Board Member, Pediatrics in Review.)

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