Session VII - Pediatrics

The Incidence of Compartment Syndrome in Ipsilateral Fractures of the Humerus and Forearm in Children

Laurel C. Blakemore, MD; Daniel R. Cooperman, MD; George H. Thompson, MD; Cynthia Wathey, RN; R. Tracy Ballock, MD, Case Western Reserve University, Cleveland, OH

Purpose: Ipsilateral fractures of the humerus and forearm are uncommon injuries in children. The existing literature does not suggest an increase in the incidence of forearm compartment syndrome in ipsilateral humerus and forearm fracture when compared with either injury in isolation. We hypothesized that the incidence of compartment syndrome in ipsilateral forearm and humerus fractures is higher than that associated with either fracture alone. This report reviews our experience with ipsilateral humerus and forearm fractures over a thirteen-year period.

Materials and Methods: We performed a retrospective review of the existing computerized databases for MetroHealth Medical Center and Rainbow Babies and Children's Hospital. 260 MetroHealth Medical Center records included all children younger than 16 years of age who were admitted between January 1, 1991 and October 31, 1997 with an upper extremity fracture. At Rainbow Babies and Children's Hospital 675 records were available from January 1, 1984 to October 31, 1997 that met these criteria. From these 935 cases, 47 children were identified as having sustained ipsilateral fracture of the humerus and forearm. A total of 4 were excluded because of incomplete records, the presence of only avulsion fractures, or fractures of indeterminate age. The remaining 43 children form our study group.

Results: The incidence of compartment syndrome occurring with isolated humerus fractures was 0.79% at Hospital A and 0.5% at Hospital B. Forearm fractures were associated with compartment syndromes in 0.75% and 0.79% of cases respectively at these institutions. Among 43 children with ipsilateral fracture of the humerus and forearm, 3 children underwent fasciotomies for compartment syndrome; the incidence of compartment syndrome in that group was therefore 7%. All 3 who were diagnosed with compartment syndrome and underwent forearm fasciotomies had sustained a Gartland III supracondylar humerus fracture and displaced ipsilateral forearm fracture.

The average age of 43 children with ipsilateral fractures of the humerus and forearm was 8 years (range 2 months-15 years); 14 of those children sustained a Gartland Grade III supracondylar humerus (SCH) fracture. The average age in our subset of these children who sustained a Gartland III SCH fracture and ipsilateral forearm fracture was also 8 years, with a narrower range of 4 years 8 months to 13 years. Of the 14 cases of ipsilateral Gartland III SCH fractures and forearm fractures, 9 involved displaced forearm fractures and underwent reduction of the forearm fracture and cast or splint application in addition to operative treatment of the SCH fracture. Ten of the 14 Grade III SCH fractures were treated by closed reduction and percutaneous pinning and 4 required open reduction and pinning. The incidence of compartment syndrome in patients with ipsilateral Gartland Grade III SCH and displaced forearm fracture was 33%, while in those children with ipsilateral Gartland Grade III SCH and non-displaced forearm fractures the incidence was 0%. All 3 children with compartment syndromes were injured in falls from heights of 4 to 6 feet. Two required fasciotomy at 18 to 24 hours following their index surgery for evolving neurolgical deficit. The other underwent fasciotomy with the index surgery when the volar compartment became firm and compartment pressure was measured at 42 mm Hg. Two of the three children demonstrated temporary neurologic deficits that resolved fully at one week and eight months, respectively. All three children showed satisfactory healing of their fracture radiographically at an average of six weeks post-operatively.

Discussion: The incidence of compartment syndrome with isolated fractures of the humerus or forearm at our institutions was approximately 0.7%. Review of the literature suggests that this is consistent with other reports. Studies describing ipsilateral humerus and forearm fractures report incidences of compartment syndrome ranging from 0% to 12.5%; the largest series of 56 cases reported by Reis and associates found no associated compartment syndromes. Among our 43 patients with ipsilateral humerus and forearm fractures, the incidence of compartment syndrome was 7% and rose to 33% when we considered Grade III SCH fractures and displaced forearm fractures requiring reduction. Our findings suggest that children who sustain Grade III supracondylar humerus fracture and ipsilateral displaced forearm fractures are at significant risk for development of compartment syndrome and should be closely monitored during the perioperative period for signs and symptoms of rising intracompartmental pressures in the forearm.