Pediatric emergency medicine trisk 3981 3981
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Current Evidence
Compartment syndrome refers to vascular insufficiency caused by elevated tissue
pressures that usually occurs after an injury involving hemorrhage or edema
within an enclosed fascial compartment. Tight circumferential bandages or casts
can also limit expansion of swollen tissues and result in elevation of tissue
pressures. Fluid extravasation from intravenous or intraosseous lines, especially
pressure-driven extravasation, may significantly elevate compartment pressures.
Direct injury to an artery is less common as the cause of vascular insufficiency
after injury but is also considered as compartment syndrome. Increased intraabdominal pressure from various causes including intestinal obstruction and
burns can cause an abdominal compartment syndrome that is immediately lifethreatening due to inferior vena cava compression and reduced venous return.
When compartment pressures approach the perfusion pressure of muscle,
which is approximately 30 mm Hg, arterial inflow is reduced and veins and
capillaries are collapsed. Ischemia of muscle leads to further swelling, and a
positive feedback loop of ischemia—edema can further elevate tissue pressures
and lead to complete cessation of perfusion. Muscle necrosis is irreversible after 6
to 8 hours of tissue anoxia. Fibrosis develops and ischemic contracture results in
permanent disability.
Clinical Considerations
Clinical Recognition
The emergency clinician must identify patients at risk for compartment
syndromes, and consult with an orthopedist who can monitor tissue pressures and
treat compartment syndromes before irreversible injury occurs.
Knowledge of the common pediatric injuries that are associated with
compartment syndromes can raise the clinician’s index of suspicion appropriately.
Lower leg fractures of the tibia and/or fibula are responsible for 60% of
compartment syndromes. Fractures that are open are at greater risk for the
development of a compartment syndrome, perhaps because they result from
higher-energy mechanisms. Displaced supracondylar fractures may injure the
anterior interosseous artery and the flexor compartment of the forearm causing a
compartment syndrome that leads to the classic Volkmann contracture. Though
controversial, some have suggested that delayed reduction is a risk factor for
compartment syndrome after supracondylar fracture. Forearm fractures may also
cause compartment syndromes, affecting either the flexor or extensor
musculature. Compartment syndromes may occur from crush injuries and other
