Rationale: Acute compartment syndrome (ACS) is a feared complication following traumatic injuries. We describe the occurrence of silent ACS of the hand in a 2-year old patient with atypical symptoms. Patient concerns: Our patient experienced massive swelling but minimal pain of the hand after a heavy bistro table with a stone tabletop had fallen on the right hand. Diagnosis: After monitoring the development of ACS for 1 night, we noted increased firmness of the swelling and impaired perfusion of the skin covering the palm and dorsum of the hand. Notably, the patient held the hand in an intrinsic minus position but did not complain of pain after administration of only a single (weight-matched) dose of ibuprofen. Our suspicion of ACS was confirmed intraoperatively because of the elevated intramuscular pressure (up to 60 mm Hg) in several hand compartments. Interventions: We performed surgical fasciotomy of all hand compartments, followed by temporary coverage of the wounds with Epigard synthetic skin substitute. The wounds were closed stepwise after 2 and 7 days, and occupational therapy was initiated after 3 weeks. Outcomes: At the 1-year follow-up, we noted unrestricted wrist and finger functions of the patient. The parents reported that there was no difference in the use of the 2 hands during daily activities. Lessons: The possible development of ACS should be borne in mind even in the absence of marked pain. Although the 3 A's (i.e., anxiety, agitation, and increased analgesic requirements) in the diagnosis of ACS in children are well established, some patients may experience only minimal pain. This challenges the correct and timely diagnosis of ACS in children, particularly if they are very young.

Elastic stabile intramedullary nailing (ESIN) is a well-established method to stabilize diaphyseal fracture of the femur (DFF) in children. We aimed to evaluate the minimal medullary canal diameter (MMCD) of the fractured femur relative to the diameter of the nails. We also analyzed the real anteversion angle (AVA) of the affected femur in comparison to the healthy femur. We retrospectively reviewed the medical records and plain X-ray images of children aged 2–15 years treated with ESIN for unstable femoral shaft fractures between 2004 and 2012. We measured MMCD on preoperative plain X-ray images. Nail diameter (ND) and any postoperative complications were extracted from the medical records. At follow-up conducted at a median of 40 months (range: 4–103 months) after the operation, we obtained Dunn X-ray images of both hips. Particular emphasis was placed on postoperative torsional differences in relation to age, weight, and maturity of the growth plate. We analyzed the relationship between postoperative rotational malalignment and the ratio of ND to MMCD. Median age of the 22 children at the time of injury was 7.5 years (range: 2–15 years). Median body weight was 25 kg (range: 13–57 kg). Median MMCD amounted to 8.6 mm (range: 5.5–11.0 mm). Median ND/MMCD was 36.9% (range: 27.3%–47.4%). Radiological analyses revealed a median of 27.0° (range: −22.0° to +49.0°) of real AVA in the affected leg and 32.5° (range: 18.0°–48.0°) in the healthy leg. Three children (13.6%) experienced a grade III complication (Clavien–Dindo classification of surgical complications; CDCSC). Two of these children suffered retrotorsion of the femoral neck, while the third child experienced diminished anteversion. Overall, 3 of 22 children (13.6%) suffered a CDCSC-grade III complication (i.e., retrotorsion of the femoral neck in two children and diminished anteversion of the femoral neck in one child). We recommend obtaining Dunn images at the end of the operation to confirm correct rotational alignment after stabilization with ESIN. Further prospective studies are required to confirm our findings.

ZusammenfassungDie Einteilung der suprakondylären Oberarmfraktur erfolgt im deutschsprachigen Raum nach der Von-Laer-Klassifikation, die von der AO übernommen wurde und den Vorteil bietet, dass daraus die Therapie ableitbar ist. Wenn indiziert, wird die sofortige Operation einer zeitnahen verzögerten Versorgung vorgezogen. Das Ergebnis wird anhand funktioneller Tests direkt im OP kontrolliert. Frakturinstabilität und korrektes Platzieren der Kirschner(K)-Drähte stellen Herausforderungen dar. Alternativen sind Fixateur externe und elastisch stabile intramedulläre Nagelung (ESIN). Begleitende Verletzungen betreffen initial den N. medianus und die A. brachialis, in zweiter Linie den N. radialis. Der N.-ulnaris-Schaden ist meist eine postoperative Komplikation. Die knöcherne Konsolidation ist nach 3 bis 4 Wochen gegeben; danach können eingebrachte Implantate entfernt werden. Versenkte K‑Drähte und ESIN werden nach 3 bis 6 Monaten entfernt, je nach operativer Kapazität und Beschwerden des Patienten.

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