Volar Compartment Research Articles

Forearm Compartment Pressure Change in Children Operated for Supracondylar Humerus Fracture.

The aim of this study is to examine the preoperative and postoperative forearm compartment pressures in patients treated operatively for Gartland type III extension type supracondyler humerus fractures and understand the course of these values over postoperative period. Deep volar compartment pressure of 31 patients were measured in the proximal one third of the forearm preoperatively, and measurements were continued every 4 hours for the first 24 hours after the operation with a catheter. Type of the reduction technique (open reduction vs. closed reduction), duration of surgery, the time from the injury to surgery were all evaluated. In the measurements made immediately after the operation (0 h), a sudden increase in the compartment pressure was detected in all patients (15.0±5.9 to 27.9±7.5mmHg) independent of the reduction technique and gradually decreased over time. The mean compartment pressure at the 12th hour postoperatively was higher in the open reduction group than in the CR group (24.5±3.4, 20.7±6.7mmHg, respectively) ( P =0.044). The mean preoperative compartment pressure was 17.7±5.8mmHg in patients with a time from injury to surgery longer than 12 hours, and 12.4±4.8mmHg in patients with 12 hours or less ( P =0.006). The postoperative 0-, 12-, and 20-hour pressure values were higher in the >1 hour operation time group than in the ≤1 hour group and the differences were statistically significant ( P =0.046, 0.016, and 0.032, respectively). In pediatric supracondylar humeral fractures, those who underwent open reduction had higher preoperative and postoperative compartment pressures. The reduction attempt was found to be a factor that increased the compartment pressure and after the operation, the compartment pressure values decrease gradually. Prolonged operative time (>1h) and increased time from injury to operative fixation (>12h) were associated with higher compartment pressures. Level II-prospective study.

Delayed Presentation of a Traumatic Radial Artery Pseudoaneurysm

<h3>Introduction & Objective</h3> Radial artery pseudoaneurysms are rare and almost exclusively iatrogenic in origin. Post- traumatic radial artery pseudoaneurysms are even more uncommon, and relevant literature is limited to few case reports which mainly describe an acute presentation and management via external compression, thrombin injection, resection and bypass graft, or radial artery ligation. This case describes a rare diagnosis of traumatic radial artery pseudoaneurysm with a delayed presentation and successful resection with primary end-to-end anastomosis. <h3>Case Report</h3> A 29-year-old right-handed man sustained gunshot wounds to his bilateral forearms. He underwent surgical intervention on his left forearm at an outside institution; his right forearm was managed conservatively. His right forearm was asymptomatic until about one-week post-injury when he lifted groceries and experienced acute forearm pain and subsequent edema. He gradually developed a right forearm mass and increasing pain until 22 days post-injury when he noted decreased right-hand motor function, prompting presentation to our emergency department. A ∼1 cm pulsatile mass on the volar right forearm was noted, and his right proximal and distal interphalangeal joints were in flexion with limited weak extension (Figure 1Figure 1Preoperative Appearance of Right Forearm & HandFigure 1). Volar compartment pressure was normal. CT arteriogram revealed a right forearm hematoma and adjacent short segment of radial artery non-visualization. Ultrasound detailed a 1.4 cm pseudoaneurysm of the right radial artery (Figure 2Figure 2Ultrasound of Pseudoaneurysm with Pathognomonic "Yin-Yang" SignFigure 2) with distal reversal of flow and biphasic doppler signals. Ulnar and palmar arch doppler signals were triphasic with radial artery occlusion. We proceeded to the operating room for right forearm exploration and a large hematoma was evacuated. The radial artery pseudoaneurysm had active extravasation from an anterolateral 7mm segmental disruption of over 50% circumference (Figure 3Figure 3Radial Artery Segmental DisruptionFigure 3). The pseudoaneurysm was resected, and successful tension- free repair performed via primary end-to-end anastomosis (Figure 4Figure 4Radial Artery Following Pseudoaneurysm Resection & Primary AnastomosisFigure 4). At procedure completion triphasic distal radial artery and palmar arch doppler signals were identified. His right-hand motor function significantly improved immediately after surgery, with return to baseline over the following days. At one month follow-up his right radial pulse remained palpable and right hand had no residual deficit. <h3>Discussion</h3> Radial artery pseudoaneurysms are uncommon, but with progressive widespread adoption of trans-radial access for cardiac catheterization and recent literature on growing applications for noncoronary endovascular procedures the incidence is expected to rise. Radial artery pseudoaneurysms can carry significant morbidity including compartment syndrome, critical limb ischemia, and digital necrosis. Providers performing trans-radial procedures should maintain a high index of suspicion for this complication to avoid compromise of functional status and optimize patient outcomes.

AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome.

AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome.

Telemedicine-guided forearm emergency decompressive fasciotomy for compartment syndrome

Introduction We highlight the utility of telemedicine and telementoring for the management of orthopaedic emergencies using a case of forearm compartment syndrome following a penetrating trauma in a northern Inuit community in Nunavik, Quebec, Canada. Methods & Results As in many cases of compartment syndrome in rural settings, the patient was at a high risk of developing irreversible complications. A prompt diagnosis followed by an emergency decompressive fasciotomy was warranted. Using telemedicine and telementoring guidance, the diagnosis of compartment syndrome was made, and the patient’s volar compartment was successfully decompressed by a local emergency physician in a timely manner. Subsequently, the patient was able to be safely transferred to a level 1 trauma centre for further surgical management. This included a second-look operative exploration, irrigation and debridement, completion of volar fasciotomy and ulnar nerve decompression. No complications were seen. Discussion Our experience highlights two important clinical implications. First, telemedicine can be successfully implemented to facilitate clinical diagnosis of surgical emergencies in the rural setting. Second, telementoring can effectively allow surgeons to guide physicians remotely to perform emergency decompressive fasciotomy, which can help salvage the affected limb and significantly decrease the risk of debilitating complications.

Distribution of intramuscular giant lipomas in the functional compartments of the forearm: a report of 12 cases.

The aim of this study was to investigate the distribution of intramuscular giant lipomas in the functional compartments of the forearm and to compare their clinical, radiological and histopathological features with those reported in the current literature. The study included 12 patients who were surgically treated for intramuscular lipomas > 5 cm in size located in the forearm that had been confirmed histopathologically between April 2006 and March 2017. Data about the patients with respect to age, sex, affected side, localisation of the lipomas in the forearm functional compartments, size, histopathological features and recurrence were collected. According to the clinical complaints, direct radiography and magnetic resonance imaging were applied. The average diameter was 6.5 cm (range: 5.5-9 cm). All lipomas had a well-defined border. All the patients presented with soft-tissue masses that were painless in seven patients. Five patients had nerve compression symptoms. When the lipomas were classified according to the functional compartments of the forearm, six of them were located in the superficial volar compartment, two in the deep volar compartment, two in the deep dorsal compartment and two in the lateral compartment. All lipomas were surgically removed by marginal excision. None had complications or recurrence at a mean of 6.5 years follow-up (range: 1-12 years) after surgery. Intramuscular lipoma is a relatively uncommon tumour, especially in the forearm. Because of the proximity to the neurovascular structures in the forearm, excision of lipomas should be performed with care and include wide incisions. Additionally, knowing the anatomical features of the compartment where the lipoma is localised in the forearm is important in planning surgery to enable easier dissection of the lipoma and lessen the risk of damage to adjacent neurovascular structures. Level 4.

Sonoanatomy of anterior forearm muscles.

The anterior or volar compartment of the forearm contains eight muscles: five belong to the superficial group (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis and flexor carpi ulnaris), and three to the deep group (flexor digitorum profundus, flexor pollicis longus and pronator quadratus). Knowledge of the topographic anatomy is essential for correct performance of ultrasound (US) examinations and correct interpretation of the images provided.

Diagnosis and Treatment of Chronic Exertional Compartment Syndrome of the Forearm in Motocross Riders.

* Chronic exertional compartment syndrome of the forearm is most commonly found in motocross riders, and the term “arm pump” has been assigned by this population to any constellation of forearm pain experienced after riding.* Chronic exertional compartment syndrome of the forearm often results in a decrease in riders’ performance and, in some cases, requires riders to discontinue the sport altogether.* Unlike exertional compartment syndrome of the lower extremity in runners, the orthopaedic literature offers little information regarding evaluation, treatment, and management of chronic exertional compartment syndrome of the forearm.* Diagnosis of chronic exertional compartment syndrome of the forearm includes a thorough physical examination and volar compartment pressures. Literature supports pressures of ≥30 mm Hg taken at 5 minutes after symptoms begin as diagnostic for chronic exertional compartment syndrome of the forearm.* Up to 80% of riders can successfully be treated for chronic exertional compartment syndrome of the forearm nonoperatively through modification of their bike as well as physical therapy modalities.* If indicated, operative treatment of chronic exertional compartment syndrome of the forearm has up to a 95% success rate, with wide-open fasciotomy being the gold standard.

Assessment of normal forearm compartment pressures in a Nigerian population.

The forearm is prone to raised compartment pressure and it is the second most common site for compartment syndrome. The normal compartment pressure of the forearm should be known and serve as a benchmark for the diagnosis of acute and chronic compartment syndrome. This study was aimed to determine the normal compartment pressures of the forearm using a digital compartment pressure monitor. This was a prospective hospital-based study of the uninjured forearm in 30 patients, who presented with closed unilateral forearm fracture at the accident and emergency department of a tertiary health care facility, between June 2012 and December 2013. Approval was sought and obtained from institutions ethical committee. An 18gauge bevelled-tip needle, attached to a Compass TM digital compartment pressure monitor made by Mirador USA, was used to measure the pressures in the compartments of the forearm. Data obtained were analysed using the Stata 12. Significance was determined at p < 0.05. The mean age was 38.3 ± 18.3 years with male-to-female ratio of 2.3:1. The pressures in the volar compartment of the forearm ranged from 1 to 8mmHg with a mean ± SD compartment pressure of 4.7 ± 1.5mmHg. In the dorsal compartment the pressure ranged from 2 to 8mmHg with a mean ± SD of 4.9 ± 1.7mmHg SD, while the lateral compartment measurement ranged between 1 and 5mmHg with a mean ± SD of 3.6 ± 1.1mmHg. There was significant positive correlation (p < 0.01) between the compartment pressures in the volar, dorsal, and lateral compartments. The normal compartment pressure for forearm is 4.4 ± 1.6mmHg and ranged from 1 to 8mmHg from this study in our environment. This will serve as reference value when forearm compartment pressure is being measured.

Compartment Pressures in Children With Normal and Fractured Forearms: A Preliminary Report.

Acute compartment syndrome (ACS) can lead to irreversible damage if fasciotomy is not performed in a timely manner. Needle manometry is a tool to confirm suspected ACS. The threshold for compartment pressures that can be tolerated has been debated. The aim of this study is to assess the normal compartment pressures in noninjured forearms of children. Further, we sought to quantify the maximum tolerable compartment pressures in fractured forearms of children, thus establishing a baseline and providing guidance in evidence-based decision making to evaluate children with suspected ACS. This prospective study included children up to the age of 16 years with forearm fractures that needed reduction with or without osteosynthesis. Between June 2009 and March 2013, 41 children were included. Mean age was 9.25 years (range, 4 to 15.4 y). We used needle manometry to measure the pressures in the superficial and deep volar as well as in the dorsal compartments (DCs) on both the forearms. The mean pressures between compartments in healthy versus injured arms were analyzed using a 1-sided, paired t test. On the injured side, the mean compartment pressure was 19.12 mm Hg (range, 3 to 49 mm Hg) in the deep volar compartment, 15.56 mm Hg (range, 5 to 37 mmHg) in the DC, and 14.8 mm Hg (range, 2 to 35 mm Hg) in the superficial volar compartment. On the noninjured side, the mean compartment pressure was 12.9 mm Hg (range, 6 to 31 mm Hg) in the DC, 10.22 mm Hg (range, 3 to 22 mm Hg) in the deep volar compartment, and 9.66 mm Hg (range, 3 to 21 mm Hg) in the superficial volar compartment. We measured an absolute compartment pressure of >30 mm Hg in 15 patients on the fractured side. Three of them had an absolute compartment pressure of >45 mm Hg. Only 1 had ACS. This patient underwent fasciotomy and was excluded for further analysis. On follow-up (mean, 24.84 mo), no patient was found to have any sequelae of ACS. This is the first study to report normal compartment pressure measurements in noninjured forearms and in fractured forearms without clinical suspicion of ACS in children.The mean compartment pressure measured in the deep volar compartment (DVC) in healthy children was 10.22 mm Hg (range, 3 to 22 mm Hg) and therefore slightly higher than in adults. Some children with fractures tolerated absolute compartment pressures >30 mm Hg without clinical signs of ACS. Fasciotomy in children under close observation could eventually be delayed despite surpassing the accepted pressure limits for adults. Level I-prognostic.

Skeletal Muscle Metastases to the Flexor Digitorum Superficialis and Profundus from Urothelial Cell Carcinoma and Review of the Literature.

Urothelial cell carcinoma (UCC) metastases to skeletal muscle are extremely rare and usually found in patients with advanced stage cancer. The most common sites of bladder cancer metastases are lymph nodes, lung, liver, and bones. Muscle is an unusual site of metastases from a distant primary cancer, due to several protective factors. We present a rare case of 76-year-old patient with metastases in the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) muscles, 2 years after a radical cystectomy for invasive UCC of the bladder. This case is the first description of a forearm lesion, with an extensive infiltration of the volar compartments of the forearm, and the first one with a clear functional impairment.

How is forearm compliance affected by various circumferential dressings?

The forearm is the second most common location for extremity compartment syndrome. Compliance is a physical property that describes a material's ability to expand with an increasing internal volume. The effect of circumferential dressings on extremity pressures has been investigated in various animal models and in some nonphysiologic mechanical models, but the importance of this effect has not been fully investigated in the human upper extremity. In addition, the physical property of compliance has not been reported in the analysis of compartment volume-pressure relationships. We created a physiologic cadaver model for acute compartment syndrome in the human forearm to determine (1) how much volume is required to reach the pressure threshold of 50 mm Hg in forearms, undressed and dressed with various circumferential dressings, (2) differences in forearm compliances that result from dressings, and (3) whether univalving or bivalving of those dressings adequately reduces compartment pressures. A sealed inflatable bladder was placed deep in the volar compartment of seven fresh-frozen cadaveric forearms and overlying fascia and skin were closed. Compartment pressures were measured as saline was infused in the bladder, and compliance was calculated from pressure versus volume curves. This was repeated for each specimen using five external wraps, splints, and casts. At a baseline of 50 mm Hg, each dressing then was univalved (and bivalved, when appropriate for the material) and the decrease in compartment pressure was measured. For each of the seven cadaver forearms, one test was performed without dressings and then for each of five dressing conditions. Forearms in fiberglass casts accommodated only a mean of 19 mL (SD, 11 mL; 95% CI, 9-28 mL) before reaching the 50 mm Hg pressure threshold, which was much less than in undressed forearms (mean, 77 mL; SD, 25 mL; 95% CI, 55-98 mL; p < 0.001). Mean compliances were as follows: ACE™ wrap (1.75 mL/mm Hg; SD, 0.41 mL/mm Hg), Webril™ (1.54 mL/mm Hg; SD, 0.56 mL/mm Hg), Kling(®) (1.23 mL/mm Hg; SD, 0.52 mL/mm Hg), sugar tong splint (1.05 mL/mm Hg; SD, 0.52 mL/mm Hg), and fiberglass cast (0.38 mL/mm Hg; SD, 0.27 mL/mm Hg). Univalving of all circumferential wraps dropped the mean compartment pressure from the 50 mm Hg starting point: ACE™ (46%; SD, 14%), Webril™ (52%; SD, 20%), Kling(®) (70%; SD, 18%), sugar tong splint (52%; SD, 19%), and fiberglass cast (58%; SD, 7%), with p less than 0.001 for all dressings. We observed the compressive effect of various commonly used upper-extremity splints and wraps, finding the least amount of accommodation afforded by fiberglass casts. Univalve release resulted in reduction in forearm compartment pressures, even in fiberglass casts. A rigid circumferential dressing can have a dramatic effect on extremity compartment compliance. Contrary to common clinical teaching, univalving of forearm circumferential dressings effectively reduced compartment pressures, as shown in this physiologic model.

Chronic Exertional Compartment Syndrome of the Forearm in Adolescents

Chronic exertional compartment syndrome (CECS) is a well-known process, although rare in the forearm. The diagnosis is based on history, clinical examination, and compartment pressure readings. My objective is to present the largest series of CECS of the forearm in adolescents and describe my experience in its management and evolution. I reviewed 5 patients, 4 male (competing in motorcycling or motocross) and 1 female (CECS in both the legs and forearms), aged between 15 and 18 years. Volar and dorsal compartments were affected in 3 patients and isolated volar in 2 cases. The clinical diagnosis was objectively confirmed by measuring ICP with a low-pressure digital transducer (Stryker). Open fasciotomy was carried out in 4 patients. They resumed their athletic activities 6 weeks after surgery without complications, increasing their athletic performance level in line with their preoperative status. All these patients remained asymptomatic, recovering their previous competitive levels. The results were objectively classified as excellent in all 4 cases. After a mean follow-up of 6 years, the condition has not relapsed in any of the patients. Two of the patients agreed to a new ICP measurement 1 year after the surgery, showing normal values. CECS in the forearm in adolescents is a rare condition that occurs after puberty. A high index of suspicion is necessary to diagnose it. It is based on symptoms and ICP measurements. Most patients are competing motorcyclists. Surgical treatment, involving isolated decompression of the superficial volar compartment, is safe and effective (restoring normal ICP).

Compartment Syndrome of the Arm Caused by Transcatheter Angiography or Angioplasty

Compartment syndrome of the arm is a rare condition because of the large capacity of the arm compartment. Although several cases of compartment syndrome of the forearm associated with vascular access procedures have been reported, the literature contains few detailed reports of compartment syndrome of the arm caused by transcather angiography or angioplasty. This article presents 4 cases of compartment syndrome of the anterior arm caused by transcatheter angiography or angioplasty; all patients required surgical treatment and anticoagulation therapy. Following urgent fasciotomy and hemostasis, 1 patient experienced recurrent bleeding and another exhibited delayed complex regional pain syndrome of the forearm. The remaining 2 cases had good outcomes. Because all patients had been prescribed various oral anticoagulants, their compartment syndrome was considered a complication of thrombolytic therapy. In addition, because all patients had a history of multiple arterial diseases, atherosclerosis was considered to be severely advanced and the vessels to be easily damaged. Due to the authors' experiences with these 4 cases, they recommend that surgery be performed under general rather than local anesthesia and that the bleeding site be sutured or ligated. Compression of the bleeding point alone could allow heavy bleeding or recurrence of bleeding to occur because of the influence of anticoagulation therapy. Continuous bleeding of the arm may expand into the volar compartment of the forearm, leading to a condition similar to chronic compartment syndrome. Effective hemostasis, in addition to early decompressive fasciotomy, is essential in compartment syndrome caused by the catheter procedure.

Acute Calcific Tendinitis of the Flexor Carpi Ulnaris Causing Acute Compressive Neuropathy of the Ulnar Nerve: A Case Report

This study reports a case of acute calcific tendinitis of the flexor carpi ulnaris in a 64-year-old woman. She presented with symptoms of acute ulnar nerve compression mimicking a volar compartment syndrome. Owing to rapidly progressive symptoms, emergency surgical exploration was carried out. Intra-operatively a large mass of calcium phosphate carbonate was noted in association with the flexor carpi ulnaris near its insertion at the wrist compressing the ulnar nerve and artery in Guyon's canal. Postoperatively the patient had complete resolution of symptoms. Conservative management with non-steroidal anti-inflammatory drugs, rest, splinting, and steroid therapy is recommended for acute calcific tendinitis, but this case suggests a role for surgical treatment when there is acute neural compression and severe pain.

A single volar incision fasciotomy will decompress all three forearm compartments: A cadaver study

IntroductionAlthough there are three distinct compartments of the forearm, the typical approach for decompression of forearm compartment syndrome is a single incision fasciotomy of the volar compartment. This study had two purposes. The first purpose of this study was to investigate the compartment pressure changes within the forearm compartments following the creation of an acute compartment pressure using fresh-frozen cadaver forearm specimens. The second purpose was to compare the compartment pressure changes of the volar, dorsal, and mobile wad compartments at frequent intervals following a compartment fasciotomy of the forearm. Materials and methodsAn experimental study of a laboratory model of acute forearm compartment syndrome was performed at a level-one, university-based trauma centre. Eight non-embalmed human forearms from 5 male and 3 female donors with an average age of 71 years (range, 51–91) were used. Compartment pressures in the volar, dorsal, and mobile wad compartments were recorded both before fasciotomy and 1, 10, 20, and 30min after fasciotomy. ResultsA single incision volar fasciotomy was sufficient to decrease the elevated compartment pressures in the volar, dorsal and mobile wad compartments to near-baseline levels after 10min. The mean compartment pressures 30min post-fasciotomy in the volar, dorsal, and wad compartments were 2, 4, and 3mmHg, respectively. DiscussionIn a laboratory model of an acute forearm compartment syndrome, a single compartment fasciotomy may be sufficient to decrease compartment pressures in the non-released compartments (dorsal and mobile wad). Further study is necessary before changes in clinical management can be recommended.

Isolated Compartment Syndrome of the Extensor Digitorum Communis: A Case Report

Anatomically, the forearm has been shown to have a superficial and deep volar compartment, a pronator quadratus compartment [3], a dorsal compartment, and a compartment containing the mobile wad [1]. There are no reports in the literature of the EDC presenting with an isolated compartment syndrome without involving the other muscles in the dorsal compartment.

Chronic Exertional Compartment Syndrome of the Forearm in an Elite Rower

We report a case of chronic exertional compartment syndrome (CECS) affecting the volar forearm compartment of an elite rower. CECS of the forearm is a less well recognised entity than lower limb CECS. We describe a typical history and detail a potential treatment.

Compartment Syndrome in a Child Secondary to Acute Osteomyelitis of the Ulna

To the Editors: Musculoskeletal infections are common in children. On rare occasions, chronic osteomyelitis can lead to compartment syndrome. Compartment syndrome of the forearm usually develops in the presence of fractures, soft tissue damage, burns, or arterial injury.1 It is difficult to diagnose in children. Restlessness, agitation, and an increasing analgesia requirement are clinical signs of compartment syndrome.2 Prompt intervention is critical in preventing complications. We report a case of acute ulnar osteomyelitis presenting as compartment syndrome of the forearm. CASE REPORT A 5-year-old right-hand dominant male presented with 2 days of left forearm pain, swelling, and erythema. There was no history of trauma, fever, or chills. His temperature was 102.3°F on presentation. Physical examination demonstrated significant swelling of the left forearm. Any passive movement of the wrist or fingers caused severe pain. White blood cell count (WBC) was 40 K/μL (4.4–11.0 K/μL), erythrocyte sedimentation rate (ESR) was 23 mm/HR (0–15 mm/HR), and the C-reactive protein (CRP) was 93.8 mg/L (<8.00 mg/L). Blood cultures obtained showed no growth. Radiographs were normal. The clinical examination raised concern for compartment syndrome and compartment pressures were measured. The volar compartment pressure was elevated (50 mm Hg), whereas the pressure in other compartments was normal. The patient was diagnosed with acute compartment syndrome. A magnetic resonance imaging (MRI) study could not be immediately obtained. Given the urgency of the patient's condition, he was taken emergently for forearm fasciotomies and exploration. Operative Findings The patient had significant swelling over the volar forearm compartment. The fascia over this compartment was released with immediate muscle bulging. No muscle necrosis was present. Cloudy fluid was found in the deep volar compartment and was sent for Gram stain and culture. The ulna periosteum was incised and significant purulence was evacuated. A wound VAC sponge was placed over the wound, because a primary closure could not be obtained. Postoperative Course The patient was given empiric antibiotic therapy. Intraoperative cultures were positive for methicillin-susceptible Staphylococcus aureus. The patient subsequently received a peripherally-inserted central catheter (PICC) and was treated with intravenous nafcillin for 5 weeks. An MRI performed on the first postoperative day showed abnormal bone signal in the distal ulna, a subperiosteal abscess, and extensive edema. The signal change in the ulna was far distal to the area of maximal muscle swelling. The patient rapidly defervesced. He returned to the operating room where the distal ulna was drilled with release of more purulent fluid. He also underwent delayed closure of his fasciotomy incision. The patient remained afebrile after his index procedure. He was discharged home with a PICC line for antibiotic therapy. DISCUSSION Compartment syndrome has been rarely reported after chronic osteomyelitis.3 Osteomyelitis develops via direct inoculation, hematogenous spread from bacteremia, or local invasion from a nearby focus of infection. History of trauma is often associated with the development of infection either locally or at a remote site.4 When faced with a clinical picture suggesting infection with associated compartmental swelling, the differential diagnosis includes infectious myositis, necrotizing fasciitis, neoplasm such as Ewing sarcoma, and infected post-traumatic hematoma. MRI is helpful in the initial evaluation. However, delaying the initial surgical treatment of these patients to obtain imaging studies is not necessary because the radiologic diagnosis is not compromised by surgical intervention. Delayed diagnosis of compartment syndrome can lead to muscle infarction, muscle contracture, and motor or sensory deficits. Infection is rarely a problem in these cases. However, if fasciotomies are done after irreversible injury, secondary infection may develop and can lead to amputation. Mary Mulcahey, MD Nikhil Thakur, MD Stephen Tocci, MD Craig Eberson, MD Department of Orthopedics Warren Alpert Medical School of Brown University Rhode Island Hospital Providence, RI

Forearm Compartment Syndrome in the Newborn: Report of 24 Cases

Isolated cases of ischemia, compartment syndrome, or Volkmann's ischemic contracture in the forearm of the newborn infant have been reported in the past. The purpose of this study is to review a large series of patients with neonatal forearm compartment syndrome and to report the important clinical features. A search of medical records from 1980 to 2000 identified 24 children with evidence of ischemia of the forearm at the time of birth. Records and images were reviewed for prenatal and birth history, maternal factors, medical conditions, pattern of involvement, treatment, and outcomes. Patients were grouped according to the extent of initial soft-tissue involvement. All patients presented with a sentinel forearm skin lesion. Patterns of involvement ranged from mild skin and subcutaneous lesions to dorsal and volar compartment syndrome with or without distal tissue loss. Early treatment intervention was limited to a single case in which the diagnosis of compartment syndrome was made and an emergency fasciotomy was performed with a good outcome. In other cases tissue loss, compressive neuropathy, muscle loss, and late skeletal changes were responsible for impaired function. Distal bone growth abnormality was common. Forearm compartment syndrome in the newborn is not as uncommon as previously thought. The skin lesion was the common, salient, initial diagnostic finding. Early diagnosis and appropriate referral led to the salvage of a functional limb in 1 of the patients in this series. The severity of the initial insult correlated with the degree of impairment in growth and function. The delayed diagnosis and treatment of an evolving compartment syndrome may compromise further final function.

Monitoring antebrachial compartmental pressure in displaced supracondylar elbow fractures in children

Our aim was to measure antebrachial volar compartment pressure in displaced supracondylar elbow fractures in children. We conducted a prospective, observational study of 42 fractures. The mean age was 5.2 years. There was type II displacement in nine cases (21.4%) and type III in 33 (78.6%). A wick catheter (1.5 mm in diameter) was placed perioperatively and compartmental pressure was monitored on a intra-compartmental pressure monitor system (STIC monitor) with a +/- 1 mmHg margin of error. Compartmental, systolic and diastolic pressures were measured every day for the first three postoperative days and then for a 2-week follow-up period. Descriptive statistics, t-test and correlation with a P < 0.05 significance were studied. Mean compartmental pressure before reduction was 8.3 mmHg and 6.7, 4, 2.4, 1.7 and 1 mmHg during the first 3 days and at 1 and 2 weeks post-reduction, respectively. Pressure decreased 40% (P = 0.0005) from the first to the second day and 75% (P = 0.0005) from the first day to the first week. There was no correlation between compartmental pressure and systolic and diastolic pressure. The compartmental pressure decreased significantly by the third postoperative day (P = 0.02). Compartmental pressure decreased 60% the first 3 days. In displaced supracondylar fractures with clinical risk factors, it is advisable to monitor compartmental pressure during the first 24-48 h.