Acute Traumatic Compartment Syndrome in Pediatric Foot: A Systematic Review and Case Report

Crush syndrome: a review for prehospital providers and emergency clinicians

INTRODUCTION

Disasters and accidents have occurred with increasing frequency in recent years. Primary disasters have the potential to result in mass casualty events involving crush syndrome (CS) and other serious injuries. Prehospital providers and emergency clinicians stand on the front lines of these patients' evaluation and treatment. However, the bulk of our current knowledge, derived from historical data, has remained unchanged for over ten years. In addition, no evidence-based treatment has been established to date.

OBJECTIVE

This narrative review aims to provide a focused overview of, and update on, CS for both prehospital providers and emergency clinicians.

DISCUSSION

CS is a severe systemic manifestation of trauma and ischemia involving soft tissue, principally skeletal muscle, due to prolonged crushing of tissues. Among earthquake survivors, the reported incidence of CS is 2-15%, and mortality is reported to be up to 48%. Patients with CS can develop cardiac failure, kidney dysfunction, shock, systemic inflammation, and sepsis. In addition, late presentations include life-threatening systemic effects such as hypovolemic shock, hyperkalemia, metabolic acidosis, and disseminated intravascular coagulation. Immediately beginning treatment is the single most important factor in reducing the mortality of disaster-situation CS. In order to reduce complications from CS, early, aggressive resuscitation is recommended in prehospital settings, ideally even before extrication. However, in large-scale natural disasters, it is difficult to diagnose CS, and to reach and start treatments such as continuous administration of massive amounts of fluid, diuresis, and hemodialysis, on time. This may lead to delayed diagnosis of, and high on-site mortality from, CS. To overcome these challenges, new diagnostic and therapeutic modalities in the CS animal model have recently been advanced.

CONCLUSIONS

Patient outcomes can be optimized by ensuring that prehospital providers and emergency clinicians maintain a comprehensive understanding of CS. The field is poised to undergo significant advances in coming years, given recent developments in what is considered possible both technologically and surgically; this only serves to further emphasize the importance of the field, and the need for ongoing research.

Utilization of Fluorescence Microangiography in Pediatric Acute Compartment Syndrome: A Case Report

Acute compartment syndrome is a critical condition, most commonly arising as the result of high-energy trauma, fracture, and crush injury. Early diagnosis and treatment are imperative to avoid permanent functional damage to the affected extremity. Although isolated pedal compartment syndrome is well studied in adults, in the pediatric population, it has been seldom reported. Pediatric patients pose a unique challenge when diagnosing compartment syndrome. Their inability to appropriately verbalize symptoms and participate in physical examinations often causes a delay in diagnosis. We present the case of a 5-year-old female who developed compartment syndrome of her left foot 26 hours after sustaining an isolated crush injury to the distal forefoot. Her treatment included emergent fasciotomy in combination with 20 hyperbaric oxygen therapy treatments. The progression of her acute digital ischemia was monitored by using serial fluorescence microangiography studies performed at 17 hours, 7 days, and 3 weeks postinjury. Throughout these serial studies, improvement in hypofluorescence was noted involving the dorsolateral midfoot, as well as digits 3, 4, and 5, which correlated with physical examination. The patient went on to uneventfully autoamputate the distal aspects of digits 4 and 5 within 4 months of injury. At the 12-month follow-up visit, she denied any pain, sensory deficits, or functional disability and had returned to all preinjury activities. Our case study demonstrates the use of serial microangiography to monitor progression of acute ischemia associated with acute pediatric compartment syndrome and discusses prognostic capabilities.

Compartment Syndrome of the Foot: An Evidence-Based Review

Compartment syndrome of the foot (CSF) is a surgical emergency, with high risk of morbidity and poor outcome, including persistent neurologic deficits or amputation. Uncertainty remains regarding surgical approaches, pressure monitoring values, and the extent of surgical treatment. This review provides a summary of the current knowledge and reports evidence-based diagnostic and therapeutic management options for CSF. Articles describing CSF were identified from MEDLINE, PubMed, and Cochrane databases up until February 2018. Experimental and original articles, systematic and nonsystematic reviews, case reports, and book chapters, independent of their level of evidence, were included. Crush injuries are the leading cause of CSF, but CSF can present after fractures of the tarsal or metatarsal bones and dislocations of the Lisfranc or Chopart joints. CSF is often associated with persistent neurologic deficits, claw toes, amputations, and skin healing problems. Diagnosis is made after accurate clinical evaluation combined with intracompartmental pressure monitoring. A threshold value of <20 mmHg difference between the diastolic blood pressure and the intracompartmental pressure is considered diagnostic. Management consists of surgery, whereby 2 dorsal incisions are combined with a medioplantar incision to the calcaneal compartment. The calcaneal compartment can serve as an "indicator compartment," as the highest-pressure values can regularly be measured within this compartment. Appropriately powered studies of CSF are necessary to further evaluate and compare diagnostic and therapeutic options.

Compartment Syndrome with Rhabdomyolysis in a Marathon Runner

A 38-year-old female seasoned marathon runner presented to the emergency department (ED) with increasing right lower extremity pain after running two mid-distance races in one weekend. The patient had previously run many two-day races and longer distances, but recently had gained weight and had not been training. This case report details her presenting symptoms, evaluation, review of the literature, and treatment with attention to the factors that led to the development of her pathologies.

Complications of Pediatric Foot and Ankle Fractures

Ankle fractures account for 5% and foot fractures account for approximately 8% of fractures in children. Some complications are evident early in the treatment or natural history of foot and ankle fractures. Other complications do not become apparent until weeks, months, or years after the original fracture. The incidence of long-term sequelae like posttraumatic arthritis from childhood foot and ankle fractures is poorly studied because decades or lifelong follow-up has frequently not been accomplished. This article discusses a variety of complications associated with foot and ankle fractures in children or the treatment of these injuries.