ONLINE CASE REPORT Ann R Coll Surg Engl 2016; 98: e111–e113 doi 10.1308/rcsann.2016.0159
Neonatal compartment syndrome B Martin, L Treharne Cambridge University Hospitals NHS Foundation Trust, UK ABSTRACT
A term neonate was born with a grossly swollen and discoloured left hand and forearm. He was transferred from the local hospital to the plastic surgical unit, where a diagnosis of compartment syndrome was made and he underwent emergency forearm fasciotomies at six hours of age. Following serial debridements of necrotic tissue, he underwent split-thickness skin grafting of the resultant defects of his forearm, hand and digits. At the clinic follow-up appointment two months after the procedure, he was found to have developed severe flexion contractures despite regular outpatient hand therapy and splintage. He has had further reconstruction with contracture release, use of artificial dermal matrix, and K-wire fixation of the thumb and wrist. Despite this, the long term outcome is likely to be an arm with poor function. The key learning point from this case is that despite prompt transfer, diagnosis and appropriate surgical management, the outcome for neonatal compartment syndrome may still be poor.
KEYWORDS
Compartment syndrome – Neonatal – Fasciotomy – Volkmann Accepted 17 February 2016 CORRESPONDENCE TO Benjamin Martin, E: [email protected]
Compartment syndrome is defined as an increase in pressure within a fasciocutaneous compartment leading to inadequate capillary perfusion pressure. It is a well recognised complication of closed limb fractures, crush injuries, prolonged extrinsic compression, electrical injuries and revascularisation after ischaemic insult. Upper limb contracture secondary to ischaemia was first noted by Volkmann in 18811 with paralytic contracture developing as a consequence of tightly applied bandages. Although rare, neonatal compartment syndrome has been reported in the literature but it remains poorly understood in terms of aetiology and best practice. It has a broad spectrum of severity. The most severe cases have been noted to have limb length discrepancies at long-term follow-up,2 which could be a consequence of ischaemic insult to the growth plates in the affected long bones. Risk factors include prematurity, oligohydramnios, transverse lie, maternal diabetes mellitus and preterm premature rupture of membranes.3 The severity and duration of tissue ischaemia is likely to correlate with the amount of tissue loss as well as the extent of contracture. Compartment syndrome is often recognised following discolouration and swelling of the limb (indicative of underlying pathology), which develops into more severe skin changes. The differential diagnoses for this presentation should include cellulitis, necrotising fasciitis, vascular injury and amniotic band syndrome.4 As in adults, if there is suspicion of compartment syndrome, urgent decompressive fasciotomy should be performed to optimise outcome. The individual’s need for ongoing reconstruction and rehabilitation is variable. In the
largest reported series of 24 patients, improved outcomes were noted following early intervention.5
Case history A 3.37kg baby was born at 37+3 weeks’ gestation via spontaneous vaginal delivery with an Apgar score of 10 at five minutes. He had a well demarcated, grossly swollen, discoloured left forearm and hand (Fig 1). There was no difficulty in delivery. No amniotic bands were seen in the placenta, or on the arm or fingers. There were no antenatal abnormalities identified. The maternal risk factors were smoking, obesity with a booking body mass index of 41.9kg/m2 and diet controlled gestational diabetes. The 20-week fetal anomaly scan was negative. On examination, the patient’s left arm had superficial desquamation distal to the mid-forearm, with fixed staining of the skin from mid-forearm to the wrist crease volarly and to the metacarpophalangeal joints distally. The capillary refill time in the digits of the affected hand was
Neonatal compartment syndrome B Martin, L Treharne Cambridge University Hospitals NHS Foundation Trust, UK ABSTRACT
A term neonate was born with a grossly swollen and discoloured left hand and forearm. He was transferred from the local hospital to the plastic surgical unit, where a diagnosis of compartment syndrome was made and he underwent emergency forearm fasciotomies at six hours of age. Following serial debridements of necrotic tissue, he underwent split-thickness skin grafting of the resultant defects of his forearm, hand and digits. At the clinic follow-up appointment two months after the procedure, he was found to have developed severe flexion contractures despite regular outpatient hand therapy and splintage. He has had further reconstruction with contracture release, use of artificial dermal matrix, and K-wire fixation of the thumb and wrist. Despite this, the long term outcome is likely to be an arm with poor function. The key learning point from this case is that despite prompt transfer, diagnosis and appropriate surgical management, the outcome for neonatal compartment syndrome may still be poor.
KEYWORDS
Compartment syndrome – Neonatal – Fasciotomy – Volkmann Accepted 17 February 2016 CORRESPONDENCE TO Benjamin Martin, E: [email protected]
Compartment syndrome is defined as an increase in pressure within a fasciocutaneous compartment leading to inadequate capillary perfusion pressure. It is a well recognised complication of closed limb fractures, crush injuries, prolonged extrinsic compression, electrical injuries and revascularisation after ischaemic insult. Upper limb contracture secondary to ischaemia was first noted by Volkmann in 18811 with paralytic contracture developing as a consequence of tightly applied bandages. Although rare, neonatal compartment syndrome has been reported in the literature but it remains poorly understood in terms of aetiology and best practice. It has a broad spectrum of severity. The most severe cases have been noted to have limb length discrepancies at long-term follow-up,2 which could be a consequence of ischaemic insult to the growth plates in the affected long bones. Risk factors include prematurity, oligohydramnios, transverse lie, maternal diabetes mellitus and preterm premature rupture of membranes.3 The severity and duration of tissue ischaemia is likely to correlate with the amount of tissue loss as well as the extent of contracture. Compartment syndrome is often recognised following discolouration and swelling of the limb (indicative of underlying pathology), which develops into more severe skin changes. The differential diagnoses for this presentation should include cellulitis, necrotising fasciitis, vascular injury and amniotic band syndrome.4 As in adults, if there is suspicion of compartment syndrome, urgent decompressive fasciotomy should be performed to optimise outcome. The individual’s need for ongoing reconstruction and rehabilitation is variable. In the
largest reported series of 24 patients, improved outcomes were noted following early intervention.5
Case history A 3.37kg baby was born at 37+3 weeks’ gestation via spontaneous vaginal delivery with an Apgar score of 10 at five minutes. He had a well demarcated, grossly swollen, discoloured left forearm and hand (Fig 1). There was no difficulty in delivery. No amniotic bands were seen in the placenta, or on the arm or fingers. There were no antenatal abnormalities identified. The maternal risk factors were smoking, obesity with a booking body mass index of 41.9kg/m2 and diet controlled gestational diabetes. The 20-week fetal anomaly scan was negative. On examination, the patient’s left arm had superficial desquamation distal to the mid-forearm, with fixed staining of the skin from mid-forearm to the wrist crease volarly and to the metacarpophalangeal joints distally. The capillary refill time in the digits of the affected hand was
