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| CASE REPORT |
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| Year : 2018 | Volume
: 20
| Issue : 1 | Page : 63-66 |
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Acute compartment syndrome of forearm without facture in a toddler
Jai Prakash Khatri1, Munish Sood1, Ajaydeep Sud2, Manoj Kumar3
1 Department of Orthopaedics, Command Hospital, Chandimandir, Panchkula, Haryana, India
2 HoD, Department of Orthopaedics, AFMC, Pune, Maharashtra, India
3 Department of Orthopaedics, 92 Base Hospital, Srinagar, Jammu and Kashmir, India
| Date of Web Publication | 9-Jul-2018 |
Correspondence Address:
Maj Jai Prakash Khatri
Department of Orthopaedics, Command Hospital, Chandimandir, Panchkula - 134 107, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmms.jmms_58_17
Acute compartment syndrome is an orthopedic emergency. In pediatric population, there should be a high index of suspicion for its early detection, especially when it is not associated with a fracture. We present here a case of a toddler, who developed acute compartment syndrome of forearm following a trivial trauma without fracture. Pain out of proportion and increased analgesic requirement are fairly reliable signs and should raise the suspicion of compartment syndrome for the treating surgeon. Despite various methods being available for measurement of intracompartment pressure, the diagnosis largely remains clinical. Ability to actively contract the muscle in the presence of elevated compartment pressure is an indicator of the viability of muscle. The case has been presented to sensitize the young surgeons regarding the possibility of compartment syndrome following simple fall without fracture. The clinical condition was timely diagnosed, and immediate surgical decompression resulted in good functional recovery. Keywords: Acute compartment syndrome, deep volar compartment, fasciotomy, paediatric forearm
How to cite this article:
Khatri JP, Sood M, Sud A, Kumar M. Acute compartment syndrome of forearm without facture in a toddler. J Mar Med Soc 2018;20:63-6 |
| Introduction | |  |
Acute compartment syndrome, although a rare complication, remains an orthopedic emergency. There should be a high index of suspicion for its early detection, especially in pediatric population where the diagnosis is likely to be overlooked. The absence of fracture has been associated with a significant delay in the diagnosis and hence, the poorer outcome as demonstrated in various studies.[1] Here, we are presenting one such pediatric case where the patient developed acute compartment syndrome following trivial trauma without fracture and timely decompression following high index of suspicion for the clinical entity resulted in good functional recovery. The purpose of the case report is to raise awareness among the young surgeons to the possible ambiguous presentation of this condition in children following apparently trivial trauma.
| Case Report | | |
A 3-year-old female child was brought to emergency room crying with the left upper limb hanging by the side of body and complaints of pain and reluctance to use the same limb for 30 min following a fall from the bed. There was no associated injury or any known comorbidity.
On examination, swelling over volar aspect of the lower half of left forearm was noted. On palpation, it was tense, tender to touch with a normal temperature of the overlying skin. Radial artery pulsations were present on both the sides with equal oxygen saturation on photo plethysmography of fingers. The movements at elbow and wrist joint were painful and restricted. There was a marked pain on the passive extension at metacarpophalangeal joints. The child could not articulate any complaint suggestive of paraesthesia. There was no local erythema to suggest any infection or insect bite. She remained irritable and in pain throughout the examination.
X-ray of the forearm including wrist and distal arm did not show any bony injury [Figure 1]. The hematological parameters were found within normal range. Color Doppler of the affected limb was also carried out which showed normal study. Intracompartmental pressure could not be measured due to the lack of facility.
In view of the normal investigative work-up, the child was admitted, and above elbow plaster of paris slab was applied. However, the child continued to have pain which was out of proportion to the apparent injury even after Diclofenac suppository. She was reassessed every hour. In view of persistent pain and crying, the diagnosis of compartment syndrome was considered and she was taken up for fasciotomy of the volar compartment of the forearm within 6 h following injury.
Fasciotomy incision was extended from proximal to elbow crease medial to biceps tendon to 1 cm proximal to wrist flexion crease. Superficial volar compartment did not show any feature of compartment syndrome [Figure 2]. However, on exploring deep volar compartment, hematoma was noted in and around the substance of flexor digitorum profundus [Figure 3] and [Figure 4]. The deep volar compartment was decompressed, and lavage was done. The wound was closed loosely using shoelace sutures, and secondary closure was done 48 h postsurgery [Figure 5]. The patient was discharged on the 6th postoperative day. | Figure 2: Intraoperative image showing no definitive evidence of compartment syndrome in superficial volar compartment.
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 | Figure 3: Intraoperative image of deep volar compartment showing blood collection which became obvious only after exposure of deep volar compartment.
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 | Figure 4: Intraoperative image showing bleeding in and around flexor digitorum profundus.
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The wound healed without any complication and movements through the range of motion were allowed on adjacent joints. On the 6 weeks follow-up visit, the patient regained full range of motion at the elbow, wrist, and metacarpophalangeal joints [Figure 6] and [Figure 7]. | Figures 6: At 6 weeks follow-up visit, child had full range of active movements at wrist and elbow joints.
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 | Figures 7: At 6 weeks follow-up visit, child had no extension lag at interphalangeal or metacarpophalangeal joints.
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| Discussion | | |
Fracture is the most common cause of posttraumatic acute compartment syndrome amounting more than two-third of the cases. Soft tissue injury remains the second most common cause.[2] In the presented case, the child developed acute compartment syndrome following trivial trauma without any associated fracture. Prasarn et al.[3] in their study identified 13 pediatric cases of acute compartment syndrome without fracture and obtained normal functional outcome in only 58% of cases with three patients requiring amputation as compared to Bae et al.[4] who demonstrated good outcome in 90% of cases which were associated with a fracture.
Various series have given their mean injury to diagnosis interval ranging from 18.2[5] to 31.1 h [6] in those aged <3 years. However, in the above case, the child was kept under constant observation and injury to surgery interval was <12 h. Clinical features of acute compartment syndrome include swelling, pain out of proportion to the sustained injury, and paraesthesia in early stages.[4],[7] Increased analgesic requirement and difficulty in consoling the patients have been demonstrated as early and fairly reliable indicators of impending compartment syndrome [4],[8] and were noted in our case. Firm swelling of the forearm was noted; however, manual palpation for the assessment of compartment firmness has been found to be an unreliable tool for diagnosis of compartment syndrome with a sensitivity of around 54%.[8] Pulselessness, pallor, and neurodeficit are late and inconsistent features encountered infrequently.[4]
The subtle initial presentation of compartment syndrome in children has led several authors to recommend routine measurement of compartment pressures in uncooperative and very young patients or those having altered mental status with inconsistent clinical symptoms.[3],[4],[9] Apart from conventional methods, near-infrared spectroscopy,[10] and radiofrequency identification implants [11] have also been utilized. However, there are other studies which suggest that the diagnosis of acute compartment syndrome can be made on clinical grounds alone and should not be delayed for want of compartment pressure measurement.[12]
The exact time of onset of increased intra-compartmental pressure is not known in the majority of the patients, and clinical judgment is of paramount importance. Ability to contract the muscles of the involved compartment voluntarily indicates muscle viability and decompression should be done immediately.[12]
Even though, irreversible damage has been demonstrated in canine studies after 8 h,[13] pediatric population has been shown to be more resilient than adults and have a better recovery even after a significant delay of up to 48–72 h in the diagnosis and treatment.[14],[15] Flynn et al. in their study displayed excellent outcome in thier series despite delay in fasciotomy.[5] The deep volar compartment muscles are most commonly damaged ones in forearm compartment syndrome.[16] The same was found to be involved in the presented case. However, a high index of suspicion for the clinical entity and timely surgical decompression helped us to achieve a good functional outcome.
| Conclusion | | |
In summary, acute compartment syndrome of the upper extremity is a rare but potentially devastating condition that remains difficult to diagnose in the pediatric population in the absence of intra-compartment pressure measurement. Prompt diagnosis and immediate surgical decompression are vital to obtain a satisfactory clinical outcome. In pediatric patients with apparently low energy soft tissue injury, the possibility of compartment syndrome should always be considered to prevent long-term sequalae.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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