Compartment syndrome in children and adolescents

Grottkau, Brian E.; Epps, Howard R.; Scala, Carla Di

doi:10.1016/j.jpedsurg.2004.12.007

Cited by 103 publications

(81 citation statements)

References 15 publications

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“…Bae et al examined 36 cases of CS in children and found that increasing analgesia requirement was a more sensitive indicator for CS in children than those used in adults [31]. The etiology of CS can be varied in children although fractures, vascular injury, and tibial osteotomies are the most commonly cited [18,[30][31][32][33]. In 1979, Mubarak and Carroll reported that supracondylar humerus fractures treated with casts and femoral shaft fractures treated with traction were the most common injuries causing upper and lower extremity CS [27].…”

Section: Discussionmentioning

confidence: 99%

“…In addition, tibial shaft fractures have been shown to be at high risk for the development of compartment syndrome (CS) in the pediatric population, presenting as the most frequent fracture linked with this condition [17][18][19][20]. Studies looking specifically at flexible nailing of tibia fractures have cited rates of CS as high as 32.0%, yet it is unclear from these studies if CS occurred before or after flexible nailing had been performed [8,11,21,22].…”

Section: Introductionmentioning

confidence: 99%

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The incidence of compartment syndrome after flexible nailing of pediatric tibial shaft fractures

Pandya¹,

Edmonds

Mubarak

2011

Journal of Children's Orthopaedics

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Purpose Pediatric tibial shaft fractures are common injuries encountered by the orthopaedic surgeon. Flexible intramedullary nailing has become popular for pediatric patients with tibial shaft fractures that require operative fixation. The purpose of our study was to evaluate the incidence of, and the risk factors for, compartment syndrome (CS) after flexible intramedullary nailing of these injuries. Methods A retrospective review of tibial shaft fractures treated consecutively with flexible intramedullary nailing at our institution from 2003 to 2010 was performed. The incidence of CS after flexible nailing was recorded. In addition, age, weight, mechanism of injury, polytrauma, presence of an open fracture, presenting neurovascular exam, fracture pattern, delay in treatment ([24 h from injury), prior closed reduction attempts, method of reduction (open vs. closed) in the operating room, total fluoroscopy time, and operative time were recorded. Comparisons were made between children who developed CS and those who did not. Results Thirty-one children met inclusion criteria with a mean age of 11.2 years (range, 6.3-15.3 years); all were boys. Nearly, 20% of children developed CS after flexible nailing of their fractures. Those who developed CS after flexible nailing were heavier than the unaffected group (52.6 ± 14.5 kg vs. 39.4 ± 15.2 kg, P = 0.05); with a greater percentage of children 50 kg or greater (83.3% vs. 26.1%, P = 0.02) within the CS group. Children who developed CS were also more likely to present with neurologic deficits in the absence of compartmental swelling prior to surgery (66.7% vs. 9.1%, P = 0.009), and more likely to have comminuted/complex fracture patterns (83.3% vs. 29.1%, P = 0.02). There was no difference between patients who did and did not develop CS in regards to age (P = 0.42), high-energy injury mechanism (P = 0.30), polytrauma (P = 1.0), delay in treatment (P = 0.28), prior closed reduction attempts (P = 1.0), method of reduction (open vs. closed; P = 1.0) in the operating room, total fluoroscopy time (P = 0.96), and total operative time (P = 0.45). In addition, there was no difference (P = 0.65) in the rates of CS between children with open and closed fractures. Conclusions There is a high risk of CS after flexible intramedullary nailing of pediatric tibial shaft fractures regardless of whether an injury is open or closed. Variables that would seemingly be associated with the development of CS (high-energy injury mechanisms, polytrauma, treatment delay, prior closed reduction attempts, and closed reduction in the operating room) were not statistically associated with CS in our study. Clinicians should be wary for the development of CS whenever utilizing flexible nails for tibial shaft fractures, especially when the following co-morbidities are present: the child weighs greater than 50 kg, has complex/comminuted fracture patterns, or has a neurologic deficit in the absence of compartmental swelling prior to operative intervention.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The incidence of compartment syndrome after flexible nailing of pediatric tibial shaft fractures

Pandya¹,

Edmonds

Mubarak

2011

Journal of Children's Orthopaedics

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“…1,3,4,13 Patients with other types of fractures and those admitted with the diagnosis of compartment syndrome were excluded. A correctly ordered neurovascular assessment was defined as an order for neurovascular assessment every 2 hours for an at-risk patient.…”

Section: Operational Definitionsmentioning

confidence: 99%

“…[1][2][3][4][5] ACS development is variable and unpredictable, and delay in recognition or treatment of ACS can lead to significant disability including vascular compromise, tissue and muscle necrosis, limb loss, neurologic deficits, or death. [1][2][3][4][5][6][7][8][9] The true incidence of ACS in children is uncertain.…”

mentioning

confidence: 99%

“…However, the literature suggests that these symptoms are unreliable and often late findings, especially in children, where it is often more difficult to achieve cooperation and communication for accurate assessment. 1,3,4,6,10 After a serious safety event involving a failure to diagnose ACS at our institution, we identified a lack of awareness about ACS among physicians and nurses and inconsistency with orders and monitoring of patients at greatest risk for developing ACS. This was thought to result in part from a high proportion of orthopedic surgery residents (who are the primary hospital providers for these patients) based at other institutions who rotate at our hospital.…”

mentioning

confidence: 99%

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A Collaborative System to Improve Compartment Syndrome Recognition

Schaffzin¹,

Prichard

Bisig

et al. 2013

Pediatrics

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BACKGROUND AND OBJECTIVE: Acute compartment syndrome (ACS) is a rare but serious complication of extremity injury that can cause permanent damage or death. ACS development is variable and unpredictable, and delay in recognition or treatment of ACS can lead to significant morbidity. Our objective was to create a reliable system for recognition of patients at risk and monitoring for ACS that could withstand frequent provider turnover. METHODS:Using the Model for Improvement, we identified key drivers and failure modes for 2 processes: resident and nurse practitioner proper order entry and bedside nurse proper documentation of monitoring. Interventions were tested in frequent plan-do-study-act cycles. Effective interventions were used in combination to test for sustainability. RESULTS:Proper order entry increased from 23% at baseline to 90%. Proper documentation for patients with correct orders increased from 15% to 70%. Individual interventions, including pocket card distribution, electronic medical record order set, and direct discussion by team leaders, were associated with improvement among residents but were not sustained with team turnover. Incorporating all 4 individual interventions into the on-boarding process for residents produced consistent success. Nursing documentation improved with education and maintenance of proper order entry. CONCLUSIONS:We built a reliable, sustainable system to recognize and monitor patients at risk for ACS. Interventions designed to minimally disrupt existing workflows were individually associated with improvement. We achieved sustainability through staff turnover when we incorporated the interventions into routine orientation for new staff. Hospitals can use existing orders and protocols to sustain surveillance for ACS and other acute conditions. Pediatrics 2013;132:e1672-e1679 AUTHORS:

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