Acute compartment syndrome in children; beware of “silent” compartment syndrome

Abstract

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.

Diagnostics and Treatment of Volkmann Ischemic Contracture in a Seven-Year-Old Child

“…10,19 Even in the absence of pain and the presence of symptoms such as severe swelling and impaired or inconspicuous neurovascular function, a possible silent ACS needs to be taken into account and treated timely. 11 Despite the remaining limitations mainly consisting of the lack of strength in finger flexion and an impairment of full extension in the wrist, our patient leads a happy life pursuing his hobby swimming, where he feels no restrictions at all and competes on a national level. We are content with the success of our interdisciplinary team effort and wish our patient the best for his future.…”

“… 10 19 Even in the absence of pain and the presence of symptoms such as severe swelling and impaired or inconspicuous neurovascular function, a possible silent ACS needs to be taken into account and treated timely. 11 …”

“… 10 In children, however, the primary symptoms are rather summarized as the three “A's”: anxiety, agitation, and increased analgesic requirements due to pain out of proportion along with pain on passive stretching. 11 Increasing pain and firmness of a muscle compartment on palpation over time may indicate the presence of a sub-ACS. But even in the absence of pain, a compartment that is rigid on compression with impairment of peripheral blood perfusion can lead to the diagnosis of silent ACS.…”

Pediatric Acute Compartment Syndrome

“…The risk for "silent" compartment syndrome has been highlighted. 55 Concerns regarding the effect of PCA analgesia or regional anesthetic techniques on the clinical ability to detect compartment syndrome have generated discussion in both the pediatric and adult literature. 5,[56][57][58] While publications in the anesthesia literature conclude that there are no convincing evidence that regional anesthesia, epidurals, or PCAs the anesthetic methods contribute to delays in diagnosis, the concern persists among orthopaedic surgeons.…”

Painless Compartment Syndrome

“…Early diagnosis and emergent fasciotomy are vital for the relief of intracompartmental pressure and to avoid irreversible damage. Delayed diagnosis can lead to complications ranging from residual disability to amputation [4].…”