Pediatric emergency medicine trisk 3982 3982
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soft tissue trauma that does not necessarily involve a fracture. Poisonous
snakebites, especially pit vipers, and deep tissue infections such as myositis or
fasciitis may also lead to dangerous elevations of compartment pressures.
Clinical Assessment/Initial H&P
The “five Ps” of compartment syndrome is a mnemonic that should be replaced
by the “three As.” Pain alone is often the only early symptom or sign of vascular
insufficiency when interventions should be started. Anxiety, Agitation, and
Analgesia requirement, which are manifestations of pain in children, should
provoke consideration of compartment syndrome. The astute clinician should
suspect compartment syndrome and consult an orthopedic surgeon before
paresthesia, pallor, paralysis, and pulselessness are present.
Pain, the hallmark of compartment syndromes, is a symptom in almost all
significant injuries. Distinguishing the pain from the injury itself from that related
to the vascular insufficiency is difficult. Pain that increases over time or seems
out of proportion to the injury itself suggests muscle ischemia. Full extension of
the fingers or toes stretches ischemic muscles and exacerbates the pain in
compartment syndromes, making this part of the examination especially
important in patients at risk for compartment syndromes.
Paresthesia may be noted in the distribution of the nerves that traverse the
ischemic compartment. When the flexor compartment of the forearm is involved,
the median nerve is usually affected. Over time, paresthesias may progress to
complete anesthesia, and pain may decrease.
Pallor from decreased perfusion may be noted distally. Sluggish circulation
may cause cyanosis. Paralysis is a late finding and is probably the least sensitive
marker for compartment syndrome. Pulselessness is a useful finding if present,
but some physicians are falsely reassured when distal pulses are palpable.
Collateral circulation can preserve pulses in larger vessels but the ischemia in
compartment syndromes results from vascular occlusion of small vessels.
Management/Diagnostic Testing
Treatment of a compartment syndrome should begin from the moment it is
suspected. All circumferential bandages should be removed. If symptoms persist,
measurement of compartment pressures should be obtained, by the emergency
clinician or in consultation with an orthopedic surgeon. Reduction of displaced
fractures can improve blood flow to affected compartments. Fasciotomy in the
operating room is indicated if compartment pressures remain high.
