Session IX - Pediatrics and Spine
Incidence of Compartment Syndrome in Pediatric Upper Extremity Fractures after Closed Reduction and Immediate Circumferential Cast Application
Anshuman Singh1; Vikas V. Patel, MD1; Tania A. Ferguson, MD2; James Policy, MD2; Scott Hoffinger, MD2;
Purpose: Fracture reduction followed by cast application is frequently the definitive treatment for pediatric fractures. The quality of the cast is important to avoid reduction loss and malunion. Historical reports have indicated that 16% of Volkmann's contractures are secondary to forearm fractures and that 21% of pediatric compartment syndromes are secondary to upper extremity fractures. On the basis of these reports, many physicians apply splints after fracture reduction in children. The incidence of compartment syndrome after acute fracture reduction and immediate casting has not been reported. The objective of this study was to determine the complications involved with acute casting of pediatric upper extremity fractures and to analyze the incidence of compartment syndrome involved with this technique.
Methods: We carried out a retrospective review of 455 patients treated for acute fracture of the upper extremity with closed reduction and immediate circumferential casting at a level 1 pediatric trauma facility from May 1999 to February 2002. Patients were excluded if a reduction was not performed or if they did not have at least 4 weeks of follow-up. The patients' charts were reviewed and evaluated for fracture pattern, age, loss of reduction, need for subsequent surgery, length of follow-up, and complications.
Results: We found that 423 patients, 2 months to 17 years of age, with upper extremity fractures were treated by closed redution with immediated circumferential casting. The average follow-up was 9.8 weeks (range, 4 weeks to 2 years.) Both-bone forearm fractures were the most common fracture pattern (N = 236, 56%) followed by distal radius fractures (N =175, 41%). There were five elbow fracture-dislocations, three Monteggia, and four Galleazzi fractures. Of the 236 both-bone fractures, 9.4% (N = 22) required surgical treatment for inadequate or lost reduction. The average age of these patients was 7.81 (range, 2 months to 14 years; SD, 3.05.) One patient had a malunion after definitive treatment. Six (2.7%) of the casts required subsequent bivalving 1 to 5 days after application, two for reported paresthesias, four for complaints of tightness. The 175 patients with distal radius fractures had an average age of 9.5 years (range, 2 to 17; SD, 3.31). There were no malunions; however, six patients (3.4%) required operative treatment for inadequate or lost reductions. Casts were bivalved in seven patients (4.1%) within 5 days of application, all for complaints of tightness. There were no complications or surgical interventions for the 12 patients with elbow, Monteggia, or Galleazzi fractures. No patients developed acute compartment syndrome. The only complication that could have been attributed to an undetected compartment syndrome was one patient's fourth digit interphalangeal contracture.
Conclusion: Our experience was that fracture reduction followed by acute circumferential casting was a safe treatment for many pediatric upper extremity fractures. Our study did not include any patients with floating elbows. Patients treated for type I supracondylar fractures with casting were not reduced at this institution; therefore, these historically high-risk fracture patterns were not evaluated. Although compartment syndrome is a highly feared complication of cast application for acute fracture treatment, it was not observed in our study. Many physicians prefer to splint these fractures immediately and change to a cast in the subsequent weeks. Our experience was that this is an unnecessary practice and risks the quality of the obtained reduction.