Chapter 6: Compartment Syndrome in Children

Paul D. Choi, Frances Sharpe, Milan V. Stevanovic

Chapter Outline

Introduction

The serious and potentially devastating complications associated with compartment syndrome in adults occur in children as well. Similar to adults, compartment syndrome in children is characterized by sustained increased pressures within an osseofascial compartment resulting in circulatory impairment, ischemia, cellular anoxia, and ultimately tissue death. Failure to diagnose and treat this condition in an expeditious manner can lead to permanent disability in the affected limb. The importance of timely diagnosis and treatment is critical not only to optimize clinical outcomes but also to minimize medicolegal liability, that is, risk of malpractice claim. Delayed or missed diagnosis of compartment syndrome is one of the most common causes of litigation against medical professionals in North America.3 
Similar to adults, compartment syndrome is three to four times more prevalent in boys than in girls.2,15 A variety of injuries and medical conditions, including fractures, soft tissue injuries, burns, animal and insect bites, external compression by tight dressings, casts, antishock garments, penetrating trauma, and bleeding disorders can lead to compartment syndrome and can involve the hand, forearm, foot, lower leg, and thigh (Table 6-1). The most common mechanism of injury is trauma—secondary to motor vehicle accidents, falls, and sports.15 The majority of cases of compartment syndrome are associated with a fracture. Soft tissue injury without fracture can also commonly lead to compartment syndrome (especially in the setting of an underlying bleeding disorder or with the use of anticoagulants). It is important to maintain a high index of suspicion in soft tissue injuries without fracture. Compartment syndrome in this setting has been associated with a high rate of disability, likely associated with a delay in diagnosis and treatment.17,30 Both high- and low-energy injuries can result in compartment syndrome. Compartment syndrome can occur even in the presence of an open wound, and in one study of compartment syndrome in children, open fractures were associated with a higher incidence of compartment syndrome than closed injuries.15 Open fractures are generally associated with higher-energy injuries and the associated fascial disruption does not result in adequate decompression of all compartments. 
 
Table 6-1
Causes of Compartment Syndrome
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Table 6-1
Causes of Compartment Syndrome
Intrinsic Extrinsic
Fracture Compressive casts, dressings
Soft tissue trauma without fracture Pneumatic antishock garments
Vascular injury
Penetrating trauma
Burns Burn eschar
Animal + insect bites
Fluid infusion secondary to intravenous (or intraosseous) extravasation (also arthroscopy)
Bleeding disorders
Reperfusion injury following prolonged ischemia
Elective orthopedic procedure—osteotomy
X
Historically, acute compartment syndromes (ACSs) were more commonly reported in the forearm associated with supracondylar humerus (SCH) fractures and in the lower extremity associated with femur fractures. Likely, this was related to historical treatment methods, including casting of the elbow in hyperflexion (>90 degrees) for SCH fractures and the use of Bryant traction for the treatment of femur fractures. With advancing treatment methods, such as operative stabilization and immediate spica casting, the incidence of these causes of compartment syndromes has decreased. 
Currently, ACS in the pediatric population most commonly involves the lower leg associated with fractures of the tibia and/or fibula.12,15 Adolescents in particular are at risk and have an 8.3% rate of compartment syndrome after tibial fractures.9 In the upper extremity, ACS most commonly involves the forearm typically associated with both bone fractures of the forearm and SCH fractures.4,12,15,20 Based on a national database review, the incidence of forearm compartment syndrome following upper extremity injuries has been estimated at 1%.15 High-risk fracture patterns include displaced SCH fractures with concomitant ipsilateral forearm fractures with a rate of compartment syndrome as high as 33%4 or supracondylar fractures with a median nerve injury, which can mask the pain of compartment syndrome.25 One study found displaced fractures of the forearm that undergo multiple passes of intramedullary nails may be at a higher risk for compartment syndrome.53 

Diagnosis

The diagnosis of ACS is challenging and can be more difficult in children, especially infants, who are too young to cooperate, nonverbal, or apprehensive and crying. A high index of suspicion is recommended, especially in the setting of at-risk injuries and conditions. 
Pain, pressure, pallor, paresthesia, paralysis, and pulselessness (the six Ps) have been described as clinical markers of compartment syndrome. The reliability of these clinical findings is questionable; however, as they may be difficult to obtain in the pediatric or obtunded patient or may present too late (only after irreversible tissue damage has already occurred). Instead, the three As may be more useful in making a diagnosis of compartment syndrome in the pediatric population: Anxiety (or restlessness), agitation (or crying), and an increasing analgesia requirement.2,21 
Pain out of proportion to the injury, especially aggravated by passive motion of the involved, ischemic compartment, remains as one of the most sensitive and early physical findings of compartment syndrome.27 In particular, an increasing analgesia requirement (both in dose and frequency) can be a helpful early marker.2 Pain perception may be diminished or absent; however, and cases of “silent” compartment syndrome (i.e., absence of pain in a compartment syndrome) have been reported.1,27 Restlessness, agitation, and anxiety may be present instead, as children may not be able to report or express pain. Pressure, swelling, and tenseness may be the only objective findings of early compartment syndrome; however, these findings also tend to be unreliable physical markers of compartment syndrome.27,40 Paralysis is a late and poorly sensitive finding of compartment syndrome, and once a motor deficit develops, full recovery is rare. Pulse oximetry usually is not helpful. 
Diagnosis or exclusion of compartment syndrome on clinical grounds alone may be impossible. In these questionable clinical situations, compartment pressure measurements are recommended. In the pediatric setting, compartment pressures usually are best measured under conscious sedation or anesthesia. Accurate placement of the needle is essential. Multiple measurements at different sites and depths within each compartment are recommended. Compartment pressure measurements close to the level of fracture may be most accurate. Although controversial, the thresholds/indications for fasciotomy are an absolute pressure greater than 30 to 40 mm Hg or pressures within 30 mm Hg of either the diastolic blood pressure or the mean arterial pressure.43 Recently, normal baseline compartment pressures have been shown to be higher in (the legs of) children (13 to 16 mm Hg) compared to adults (5 to 10 mm Hg). The clinical application of this data remains unclear. 
Delayed diagnosis of compartment syndrome in children is not uncommon. This may be related to the challenges in making the diagnosis clinically in children. Other risk factors that may delay diagnosis are altered conscious level, associated nerve injury, polytrauma, and altered pain perception (possibly related to certain types of analgesia [regional]). Certain anesthetic techniques, including local anesthetics, regional anesthesia (epidural, nerve blocks), and systemic analgesics, may obscure early signs of a developing compartment syndrome and have been shown to increase the likelihood of missed compartment syndromes.2,27,52 Delay in diagnosis may also be related to longer elapsed time between the initial injury and peak compartment pressures in the pediatric setting.12 Extended close monitoring (after injury) is recommended in light of the sometimes later diagnosis of compartment syndrome in children. 
In the future, near-infrared spectroscopy (NIRS) may prove to be useful in the earlier diagnosis of compartment syndrome, as NIRS is noninvasive and capable of measuring the oxygenation state of at-risk tissues.41 
Overall, the entire clinical picture must be considered, and a high index of suspicion, especially in children who are difficult to examine, obtunded patients with blunt head injuries, or patients who are sedated, must always be maintained. 

Classification

Acute Compartment Syndrome: ACS occurs when tissue pressures rise high enough within an osseofascial compartment to cause tissue ischemia. The exact time of onset of ACS is difficult to determine. It can therefore be difficult to know the duration of tissue ischemia in a given patient. 
Exercise-induced or Exertional Compartment Syndrome: Exercise-induced compartment syndrome is a reversible tissue ischemia caused by a noncompliant fascial compartment that does not accommodate muscle expansion occurring during exercise. It has been described in both the upper and lower extremities.51 
Neonatal: Both neonatal compartment syndrome and neonatal Volkmann contracture have been reported. To our knowledge, this has only been reported in the upper extremity. It is possible that this diagnosis exists for the lower extremity but has been attributed to other causes. Awareness of this diagnosis is important, as early recognition and treatment can improve the functional outcome and growth in these patients. Although established neonatal Volkmann contracture cannot be improved by emergent intervention, awareness of this diagnosis can aid in counseling of the family and treatment of the patient (Fig. 6-1A, B). 
Figure 6-1
 
A: Neonatal compartment syndrome. Note the sentinel lesion in the forearm described by Ragland et al.31 B: Neonatal Volkmann's seen in a 5-day-old child. Necrosis present from time of birth.
 
(Courtesy of Dr. M. Stevanovic.)
A: Neonatal compartment syndrome. Note the sentinel lesion in the forearm described by Ragland et al.31 B: Neonatal Volkmann's seen in a 5-day-old child. Necrosis present from time of birth.
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Figure 6-1
A: Neonatal compartment syndrome. Note the sentinel lesion in the forearm described by Ragland et al.31 B: Neonatal Volkmann's seen in a 5-day-old child. Necrosis present from time of birth.
(Courtesy of Dr. M. Stevanovic.)
A: Neonatal compartment syndrome. Note the sentinel lesion in the forearm described by Ragland et al.31 B: Neonatal Volkmann's seen in a 5-day-old child. Necrosis present from time of birth.
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Volkmann Ischemic Contracture: Volkmann ischemic contracture is the end result of prolonged ischemia and associated with irreversible tissue necrosis. 
Several classification systems have been described for upper extremity Volkmann contracture. Most are based on the clinical severity of the presentation and are used to help direct the appropriate treatment for the identified disability. Most authors recognize the tremendous variability of the clinical presentations and the subsequent limitations of the classification system.38,48,49,54 
Seddon was the first to introduce the concept of the ellipsoid infarct involving the muscles of the proximal forearm. He further described a spectrum of contracture from mild to severe. The mild type responds to splinting with little to no residual sequelae, with the possible recurrence of contracture as a young child grows to maturity. The most severe type was described as a limb, which “apart from its envelope is gangrenous and whose treatment is futile.”38 Between these two extremes, he described three separate patterns of presentation: (1) Diffuse but moderate ischemia; (2) intense but localized muscle damage, and (3) widespread necrosis or fibrosis. 
Zancolli noted the significant variability in the involvement of the hand. His classification system was entirely based on the involvement of the intrinsic muscles.54 Types I to IV describe the severity of the intrinsic muscle involvement. The variability in presentation depends on the ischemic insult and recovery potential to the median and ulnar nerves. 
The most commonly used and our preferred classification system is that of Tsuge.48 He classified established Volkmann contracture into mild, moderate, and severe types, according to the extent of the muscle involvement. 
The mild type, also described as the localized type involves the muscles of the deep flexor compartment of the forearm, usually involving only the flexor digitorum profundus of the ring or middle fingers. It can involve all the flexor digitorum profundus and the flexor pollicis longus as well. Nerve involvement is absent or mild, typically involving sensory changes which resolve spontaneously. With wrist flexion, the fingers can be fully extended. The majority of the mild type resulted from direct trauma either from crush injury or forearm fractures, and was typically seen in young adults. 
In the moderate type, the muscle degeneration includes all or nearly all of the flexor digitorum profundus and flexor pollicis longus with partial degeneration of the flexor superficialis muscles. Neurologic impairment is always present. Sensory impairment is generally more severe in the median than in the ulnar nerve, and the hand demonstrates an intrinsic minus posture. Moderate-type injury was most commonly the result of SCH fractures in children between ages 5 and 10. 
The severe type involves degeneration of all the flexor muscles of the fingers and of the wrist. There is central muscle necrosis, and varying involvement of the extensor compartment (Fig. 6-2). Neurologic deficits are severe, including complete palsy of all the intrinsic muscles of the hand. Tsuge categorized as severe those cases with moderate involvement that are complicated by fixed joint contractures, scarred soft tissue, or previously failed surgeries. As with the moderate cases, the severe cases were most commonly the result of SCH fractures in children. 
(Courtesy of Dr. M. Stevanovic.)
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Figure 6-2
Appearance of the hand and forearm with a Tsuge severe type Volkmann contracture.
(Courtesy of Dr. M. Stevanovic.)
(Courtesy of Dr. M. Stevanovic.)
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Within each classification type, there is a broad range of clinical presentation. This heterogeneity of presentation makes it difficult to apply a specific treatment based solely on classification systems, and makes it nearly impossible to provide meaningful outcome and comparison studies. 

Treatment

Potentially devastating complications may be avoidable with early recognition and prompt intervention. The goal of treatment is to prevent tissue necrosis, neurovascular compromise, and permanent functional deficits. 
The first step is to remove all possible extrinsic causes of pressure, including circumferential dressings, cast padding, and casts. Remember that excessive limb elevation may be counterproductive; the affected limb should not be elevated higher than the patient's heart to maximize perfusion while minimizing swelling; however, a little elevation is probably better than risking a dependent limb. Optimizing overall medical management is also recommended, as shock and hypoxia may lower tissue pressure tolerance.15 
Ultimately, emergent surgical decompression (fasciotomy, i.e., release of the fascia overlying the affected compartments) is recommended for established cases. At times, release of the epimysium is also necessary. Clearly necrotic tissue should be excised as it may become a nidus for infection, but in young children questionable tissue should be left in place for a second look at a later date as discussed below. Late fibrosis of necrotic muscle can lead to compression of the adjacent nerves and result in disability of the extremity. Other procedures may be indicated based on the etiology of the compartment syndrome, including vascular thrombectomy, repair, or grafting; nerve exploration, if indicated; and fracture reduction and stabilization. Nerve repair or reconstruction when necessary should be performed at the time of definitive wound closure. 
Late diagnosis increases the risk for severe complications, including infection, neurologic injury, need for amputation, and death. Concerns about increased risk of infection have led to some recommendations not to perform fasciotomy after 24 hours of onset of symptoms. Good results however may be possible in children even when fasciotomy is performed as late as 72 hours after the injury (within acute swelling phase).12 Dramatic, essentially full, recovery has been reported following compartment syndrome of the lower leg in children even after delayed presentation.6 The potential for recovery of muscle function may be greater in a child than in an adult. This is consistent with the increased potential for recovery observed from other types of injuries in children, such as fractures, traumatic brain injuries, and articular cartilage injuries.6 As has been suggested in open fractures in children, if in doubt as to the viability of soft tissue, we recommend not to debride questionable tissue at the initial fasciotomy because the potential for tissue recovery in a child is much greater than that of an adult.11 
In the case of a delayed (or late) compartment syndrome, where fasciotomy is not indicated, for example, no demonstrable muscle function in any segment of the involved limb, the limb can be splinted in a functional position. For the upper extremity, if the resources are available for immediate reconstruction with functional free muscle transfer, then early debridement and reconstruction can reduce the incidence of late contracture and improve neurologic recovery.36,44,45 Supportive care, usually in the form of vigorous intravenous hydration, should be given for the potential risk of myoglobinuria. Myoglobinuria, as well as metabolic acidosis and hyperkalemia, can also occur during reperfusion and requires medical management especially to prevent sequelae such as renal failure, shock, hypothermia, and cardiac arrhythmias and/or failure. 

Lower Extremity

Thigh

Compartment syndromes involving the thigh are particularly rare but have been reported in the pediatric population after blunt trauma, external compression with antishock trousers, and vascular injury with or without fracture of the femur. Historically, children with femoral shaft fractures treated by skin or skeletal traction were also at risk for compartment syndrome. 
Three compartments—anterior, medial, and posterior—are described in the thigh (Table 6-2). In the thigh, a long single lateral incision can adequately decompress the anterior and posterior compartments (Fig. 6-3). Occasionally, a medial adductor incision is required as well. 
 
Table 6-2
Compartments of the Thigh
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Table 6-2
Compartments of the Thigh
Compartment Contents
Anterior Quadriceps muscle
Femoral artery, vein, and nerve
Medial Adductor muscles
Obturator nerve
Posterior Hamstring muscles
Sciatic nerve
X
Figure 6-3
Cross-sectional anatomy of the thigh.
 
Note the anterior (quadriceps), posterior (hamstrings), and medial (adductor) compartments. Entry sites for compartment pressure measurements should take into consideration the relationship between the intermuscular septa and the neurovascular structures of each compartment.
 
(Modified from Schwartz JT, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am. 1989; 71:392–400 [reprinted with permission from J Bone Joint Surg, Inc.]. From Choi PD, Rose RKT, Kay RM, et al. Compartment syndrome of the thigh in an infant: A case report. J Orthop Trauma. 2007; 21:587–590. [Courtesy of Dr. P. Choi.])
Note the anterior (quadriceps), posterior (hamstrings), and medial (adductor) compartments. Entry sites for compartment pressure measurements should take into consideration the relationship between the intermuscular septa and the neurovascular structures of each compartment.
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Figure 6-3
Cross-sectional anatomy of the thigh.
Note the anterior (quadriceps), posterior (hamstrings), and medial (adductor) compartments. Entry sites for compartment pressure measurements should take into consideration the relationship between the intermuscular septa and the neurovascular structures of each compartment.
(Modified from Schwartz JT, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am. 1989; 71:392–400 [reprinted with permission from J Bone Joint Surg, Inc.]. From Choi PD, Rose RKT, Kay RM, et al. Compartment syndrome of the thigh in an infant: A case report. J Orthop Trauma. 2007; 21:587–590. [Courtesy of Dr. P. Choi.])
Note the anterior (quadriceps), posterior (hamstrings), and medial (adductor) compartments. Entry sites for compartment pressure measurements should take into consideration the relationship between the intermuscular septa and the neurovascular structures of each compartment.
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Lower Leg

The most common presentation of ACS in children involves the lower leg following a tibia and/or fibula fracture. Compartment syndrome is also a well-known complication following tibial osteotomies for angular and/or rotational correction. 
In the lower leg, a one- or two-incision technique can be employed for decompressive fasciotomy of all four compartments—anterior, lateral, superficial posterior, and deep posterior (Table 6-3). In the two-incision technique (Fig. 6-4A), the anterolateral incision allows access to the anterior and lateral compartments. The posteromedial incision must be lengthy enough to allow for decompression of the superficial posterior compartment (more proximal) and deep posterior compartment (more distal). The soleus origin should be detached from the medial aspect of the tibia. All four compartments of the lower leg can also be adequately decompressed with a single-incision technique (Fig. 6-4B). The long lateral incision typically extends 3 to 5 cm within either end of the fibula. First, identification of the septum between anterior and lateral compartments allows access to these compartments. Next, by elevating the lateral compartment musculature, the posterior intermuscular septum is visualized and access to the superficial and deep posterior compartments is possible. 
 
Table 6-3
Compartments of the Lower Leg
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Table 6-3
Compartments of the Lower Leg
Compartment Contents
Anterior Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius
Deep peroneal (anterior tibial) vessels and nerve
Lateral Peroneus longus
Peroneus brevis
Superficial peroneal nerve
Superficial posterior Gastrocnemius
Soleus
Plantaris
Sural nerve
Deep posterior Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Posterior tibial nerve
X
Figure 6-4
Decompressive fasciotomy of the lower leg.
 
A: Two-incision approach. The anterolateral incision allows decompression of the anterior and lateral compartments. The medial incision allows decompression of the superficial posterior and the deep posterior compartments. B: One-incision approach. A single lateral incision allows decompression of all four compartments in the lower leg.
 
(Courtesy of Dr. P. Choi.)
A: Two-incision approach. The anterolateral incision allows decompression of the anterior and lateral compartments. The medial incision allows decompression of the superficial posterior and the deep posterior compartments. B: One-incision approach. A single lateral incision allows decompression of all four compartments in the lower leg.
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Figure 6-4
Decompressive fasciotomy of the lower leg.
A: Two-incision approach. The anterolateral incision allows decompression of the anterior and lateral compartments. The medial incision allows decompression of the superficial posterior and the deep posterior compartments. B: One-incision approach. A single lateral incision allows decompression of all four compartments in the lower leg.
(Courtesy of Dr. P. Choi.)
A: Two-incision approach. The anterolateral incision allows decompression of the anterior and lateral compartments. The medial incision allows decompression of the superficial posterior and the deep posterior compartments. B: One-incision approach. A single lateral incision allows decompression of all four compartments in the lower leg.
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Foot

Compartment syndromes of the foot in children are usually caused by crush injuries, such as a car tire running over a foot, and may not be associated with a fracture.42 Neurovascular deficit is infrequent. Compartment syndrome in the foot is commonly associated with a LisFranc fracture-dislocation but has been reported with fractures of the metatarsals and phalanges as well. 
In the foot, nine compartments—interosseus (4), adductor, central (2), medial, and lateral—have been described (Table 6-4). A dorsal approach through two longitudinal incisions centered over the second and fourth metatarsals may allow for adequate decompression of all nine compartments (Fig. 6-5), though many authors recommend a third incision for the medial compartment. 
 
Table 6-4
Compartments of the Foot
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Table 6-4
Compartments of the Foot
Compartments Contents
Interosseous (4) Interosseous muscles
Digital nerves
Adductor Adductor hallucis
Central (superficial) Flexor digitorum brevis
Central (deep [or calcaneal]) Quadratus plantae
Medial Abductor hallucis brevis
Flexor hallucis brevis
Lateral Flexor digiti minimi
Abductor digiti minimi
X
Figure 6-5
Decompressive fasciotomy of the foot.
 
Through a dorsal approach, two longitudinal skin incisions over the second and fourth metatarsals can be utilized to decompress all nine compartments of the foot. The superficial fascia is divided over each interspace to decompress the interosseous (I) compartments (× 4) (caution: Interosseous veins and the distal dorsalis pedis arterial branches in the first interspace). Next, the adductor, central (superficial and deep), medial, and lateral compartments are decompressed through each interspace. Many authors, however, recommend a third medial incision to decompress the medial/calcaneal compartment.
Through a dorsal approach, two longitudinal skin incisions over the second and fourth metatarsals can be utilized to decompress all nine compartments of the foot. The superficial fascia is divided over each interspace to decompress the interosseous (I) compartments (× 4) (caution: Interosseous veins and the distal dorsalis pedis arterial branches in the first interspace). Next, the adductor, central (superficial and deep), medial, and lateral compartments are decompressed through each interspace. Many authors, however, recommend a third medial incision to decompress the medial/calcaneal compartment.
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Figure 6-5
Decompressive fasciotomy of the foot.
Through a dorsal approach, two longitudinal skin incisions over the second and fourth metatarsals can be utilized to decompress all nine compartments of the foot. The superficial fascia is divided over each interspace to decompress the interosseous (I) compartments (× 4) (caution: Interosseous veins and the distal dorsalis pedis arterial branches in the first interspace). Next, the adductor, central (superficial and deep), medial, and lateral compartments are decompressed through each interspace. Many authors, however, recommend a third medial incision to decompress the medial/calcaneal compartment.
Through a dorsal approach, two longitudinal skin incisions over the second and fourth metatarsals can be utilized to decompress all nine compartments of the foot. The superficial fascia is divided over each interspace to decompress the interosseous (I) compartments (× 4) (caution: Interosseous veins and the distal dorsalis pedis arterial branches in the first interspace). Next, the adductor, central (superficial and deep), medial, and lateral compartments are decompressed through each interspace. Many authors, however, recommend a third medial incision to decompress the medial/calcaneal compartment.
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Upper Extremity

The surgical incision for fasciotomy of the arm and forearm is extensile from the brachium to the carpal tunnel. The extent of the release performed is tailored to the clinical and intraoperative findings. Release of the dorsal forearm and compartments of the hand require separate incisions when indicated (Table 6-5). Separate incision for dermotomies of each of the fingers may also be added to prevent skin necrosis and loss of the fingers. 
 
Table 6-5
Compartments of the Upper Extremity
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Table 6-5
Compartments of the Upper Extremity
Compartments Contents
Arm Anterior Biceps and brachialis, brachial artery, and median nerve
Posterior Triceps, ulnar nerve, and radial nerve
Forearm Volar Superficial FCR, PL, pronator teres, FCU, and FDS
Deep FDP, FPL, and pronator quadratus
Anterior interosseous nerve and artery
Dorsal Mobile wad Brachioradialis, ECRL, ECRB
Extensor EDC, ECU, EPL, APL, EPB, EIP, EDM, supinatora, posterior interosseous nerve
Anconeusb Anconeus
Hand Thenar Abductor pollicis brevis, opponens pollicis, and flexor pollicis brevis
Hypothenar Abductor digiti minimi, flexor digiti minimi, and opponens digiti minimi
Adductor pollicis Adductor pollicis (2 heads)
Dorsal interossei (4) Each separate compartments
Volar interossei (3) Each separate compartments
Fingers c
X

Arm

The anterior and posterior compartments of the arm can be decompressed through a single medial incision. This allows access to the neurovascular structures of the arm, the medial fascia of the biceps and brachialis in the anterior compartment, and the fascia of the triceps. Excision of the medial intermuscular septum will provide additional decompression of both compartments (Fig. 6-6). The incision can be easily extended to the elbow crease and incorporated with the incision for decompression of the forearm. This also allows release of the lacertus fibrosus and evaluation of the distal portion of the brachial artery. When there is no anticipated need to evaluate and decompress the neurovascular structures or extend the incision into the forearm, a straight midline anterior and posterior fasciotomies may be performed to decompress the flexor and extensor compartments, respectively. 
Figure 6-6
Cross-sectional anatomy of the arm is shown.
 
The dotted line represents the plane of dissection for decompression of the anterior and posterior compartments through a medial incision. The intermuscular septum can be excised which further decompresses both compartments. Alternatively, a straight anterior and posterior incision may be used to separately decompress the anterior and posterior compartments.
 
(Courtesy of Dr. M. Stevanovic.)
The dotted line represents the plane of dissection for decompression of the anterior and posterior compartments through a medial incision. The intermuscular septum can be excised which further decompresses both compartments. Alternatively, a straight anterior and posterior incision may be used to separately decompress the anterior and posterior compartments.
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Figure 6-6
Cross-sectional anatomy of the arm is shown.
The dotted line represents the plane of dissection for decompression of the anterior and posterior compartments through a medial incision. The intermuscular septum can be excised which further decompresses both compartments. Alternatively, a straight anterior and posterior incision may be used to separately decompress the anterior and posterior compartments.
(Courtesy of Dr. M. Stevanovic.)
The dotted line represents the plane of dissection for decompression of the anterior and posterior compartments through a medial incision. The intermuscular septum can be excised which further decompresses both compartments. Alternatively, a straight anterior and posterior incision may be used to separately decompress the anterior and posterior compartments.
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Forearm

Several skin incisions have been described for the forearm. Since the surgical incisions are long and extensile, almost any incision can be used to decompress the forearm compartments (Fig. 6-7). Because the incisions are left open, we prefer the incision described in the figure below, as this minimizes exposure of neurovascular structures and can be extended proximally into the medial arm and distally into the carpal tunnel (Fig. 6-8C, D). After the skin incision is made, the antebrachial fascia is opened longitudinally from lacertus fibrosis to the wrist flexion crease. This decompresses the superficial flexor compartment. The deep flexor compartment is most easily and safely exposed through the ulnar side of the forearm.34 We start at the mid to distal forearm and identify the interval between flexor carpi ulnaris and flexor digitorum superficialis. The flexor digitorum profundus and flexor pollicis longus fascia are exposed and released through this interval. This is the most important component of this procedure, as the deep flexor compartment is usually the first and most affected by increased compartmental pressure. Through the same interval, the fascia overlying the pronator quadratus is also released. 
Figure 6-7
Cross-sectional anatomy of the forearm is shown.
 
The dotted lines represent the plane of dissection for dorsal and volar compartments. The superficial flexor compartment can be released in the midline or any location, trying to avoid an incision over the radial or ulnar artery or median nerve. The deep flexor compartment is best released by opening the interval between flexor carpi ulnaris and the flexor digitorum superficialis.
 
(Courtesy of Dr. M. Stevanovic.)
The dotted lines represent the plane of dissection for dorsal and volar compartments. The superficial flexor compartment can be released in the midline or any location, trying to avoid an incision over the radial or ulnar artery or median nerve. The deep flexor compartment is best released by opening the interval between flexor carpi ulnaris and the flexor digitorum superficialis.
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Figure 6-7
Cross-sectional anatomy of the forearm is shown.
The dotted lines represent the plane of dissection for dorsal and volar compartments. The superficial flexor compartment can be released in the midline or any location, trying to avoid an incision over the radial or ulnar artery or median nerve. The deep flexor compartment is best released by opening the interval between flexor carpi ulnaris and the flexor digitorum superficialis.
(Courtesy of Dr. M. Stevanovic.)
The dotted lines represent the plane of dissection for dorsal and volar compartments. The superficial flexor compartment can be released in the midline or any location, trying to avoid an incision over the radial or ulnar artery or median nerve. The deep flexor compartment is best released by opening the interval between flexor carpi ulnaris and the flexor digitorum superficialis.
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Figure 6-8
 
A: Dorsal (extensor) incision for forearm fasciotomy. B: Release of the extensor compartment. C: Volar (flexor side) incision for forearm fasciotomy. This incision can be extended proximally into the medial arm and distally into the carpal tunnel as indicated by intraoperative findings. D: Release of the flexor compartment and carpal tunnel.
 
(Courtesy of Dr. M. Stevanovic.)
A: Dorsal (extensor) incision for forearm fasciotomy. B: Release of the extensor compartment. C: Volar (flexor side) incision for forearm fasciotomy. This incision can be extended proximally into the medial arm and distally into the carpal tunnel as indicated by intraoperative findings. D: Release of the flexor compartment and carpal tunnel.
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Figure 6-8
A: Dorsal (extensor) incision for forearm fasciotomy. B: Release of the extensor compartment. C: Volar (flexor side) incision for forearm fasciotomy. This incision can be extended proximally into the medial arm and distally into the carpal tunnel as indicated by intraoperative findings. D: Release of the flexor compartment and carpal tunnel.
(Courtesy of Dr. M. Stevanovic.)
A: Dorsal (extensor) incision for forearm fasciotomy. B: Release of the extensor compartment. C: Volar (flexor side) incision for forearm fasciotomy. This incision can be extended proximally into the medial arm and distally into the carpal tunnel as indicated by intraoperative findings. D: Release of the flexor compartment and carpal tunnel.
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During the dissection, if the muscles appear pale after release of the fascia, then additional release of the epimysium of the pale muscle should be performed. For these muscles, reperfusion injury will lead to more swelling in the muscle that will lead to further muscle injury if the epimysium is not released. 
Clinical evaluation at this time of the remaining tension in the dorsal forearm compartment and/or hand should be done to determine whether additional release of the extensor compartments and hand should be added (Fig. 6-9). 
Figure 6-9
This 7-year-old patient fell while riding a bicycle, sustaining an ipsilateral displaced SCH fracture and distal radius fracture.
 
He was seen about 4 hours after his initial injury. He was diagnosed with a compartment syndrome on presentation and taken emergently to the operating room for surgical stabilization and fasciotomy. A: Injury films showing displaced SCH fracture and distal radius fracture. B: Postoperative reduction and stabilization. C: Volar fasciotomy. D: Dorsal fasciotomy. E: Finger flexion at 1 year postinjury. F: Wrist and finger extension at 1 year postinjury.
 
(Courtesy of Dr. M. Stevanovic.)
He was seen about 4 hours after his initial injury. He was diagnosed with a compartment syndrome on presentation and taken emergently to the operating room for surgical stabilization and fasciotomy. A: Injury films showing displaced SCH fracture and distal radius fracture. B: Postoperative reduction and stabilization. C: Volar fasciotomy. D: Dorsal fasciotomy. E: Finger flexion at 1 year postinjury. F: Wrist and finger extension at 1 year postinjury.
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Figure 6-9
This 7-year-old patient fell while riding a bicycle, sustaining an ipsilateral displaced SCH fracture and distal radius fracture.
He was seen about 4 hours after his initial injury. He was diagnosed with a compartment syndrome on presentation and taken emergently to the operating room for surgical stabilization and fasciotomy. A: Injury films showing displaced SCH fracture and distal radius fracture. B: Postoperative reduction and stabilization. C: Volar fasciotomy. D: Dorsal fasciotomy. E: Finger flexion at 1 year postinjury. F: Wrist and finger extension at 1 year postinjury.
(Courtesy of Dr. M. Stevanovic.)
He was seen about 4 hours after his initial injury. He was diagnosed with a compartment syndrome on presentation and taken emergently to the operating room for surgical stabilization and fasciotomy. A: Injury films showing displaced SCH fracture and distal radius fracture. B: Postoperative reduction and stabilization. C: Volar fasciotomy. D: Dorsal fasciotomy. E: Finger flexion at 1 year postinjury. F: Wrist and finger extension at 1 year postinjury.
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The extensor compartments are released through a midline longitudinal dorsal incision extending from the lateral epicondyle to the distal radioulnar joint. This will allow release of the mobile wad and the extensor compartment (Fig. 6-8A, B). 

Hand

The hand has 10 separate compartments. It is rarely necessary to release all 10 compartments, and intraoperative assessment and/or measurement of compartment pressures should be used to determine the extent of release needed (Figs. 6-10 and 6-11). 
Figure 6-10
Cross-sectional anatomy of the hand.
 
The arrows show the planes of dissection for decompression of the compartments of the hand.
 
(Courtesy of Dr. M. Stevanovic.)
The arrows show the planes of dissection for decompression of the compartments of the hand.
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Figure 6-10
Cross-sectional anatomy of the hand.
The arrows show the planes of dissection for decompression of the compartments of the hand.
(Courtesy of Dr. M. Stevanovic.)
The arrows show the planes of dissection for decompression of the compartments of the hand.
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Figure 6-11
 
A and B: Dorsal incisions for fasciotomy of the hand and dermotomies of the fingers. C and D: Volar incisions for release of the thenar and hypothenar compartments, carpal tunnel release, and dermotomy of the thumb.
 
(Courtesy of Dr. M. Stevanovic.)
A and B: Dorsal incisions for fasciotomy of the hand and dermotomies of the fingers. C and D: Volar incisions for release of the thenar and hypothenar compartments, carpal tunnel release, and dermotomy of the thumb.
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Figure 6-11
A and B: Dorsal incisions for fasciotomy of the hand and dermotomies of the fingers. C and D: Volar incisions for release of the thenar and hypothenar compartments, carpal tunnel release, and dermotomy of the thumb.
(Courtesy of Dr. M. Stevanovic.)
A and B: Dorsal incisions for fasciotomy of the hand and dermotomies of the fingers. C and D: Volar incisions for release of the thenar and hypothenar compartments, carpal tunnel release, and dermotomy of the thumb.
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Volar Release

Decompression should start with an extended carpal tunnel release. This usually will adequately release Guyon's canal without formally opening and decompressing the ulnar neurovascular structures. The carpal tunnel incision can be extended to the volar second web space. In the distal portion of the incision, the volar fascia of the adductor pollicis muscle can be released. Also, the fascia tracking to the long finger metacarpal (separating the deep radial and ulnar midpalmar space) can be decompressed. This will help decompress the volar interosseous muscles. The thenar and hypothenar muscles are decompressed through separate incisions as needed (Fig. 6-12C, D). 
Figure 6-12
This 4-year-old girl placed a rubber band around her wrist before going to bed.
 
She was brought to the emergency room the following morning because of swelling of her hand. She was taken immediately to the operating room for compartment release. A: Volar hand prior to fasciotomy. B: Dorsal hand prior to fasciotomy. C: Volar release. D: Dorsal release. E: Finger flexion at 6 months. F: Finger extension at 6 months.
 
(Courtesy of Dr. M. Stevanovic.)
She was brought to the emergency room the following morning because of swelling of her hand. She was taken immediately to the operating room for compartment release. A: Volar hand prior to fasciotomy. B: Dorsal hand prior to fasciotomy. C: Volar release. D: Dorsal release. E: Finger flexion at 6 months. F: Finger extension at 6 months.
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Figure 6-12
This 4-year-old girl placed a rubber band around her wrist before going to bed.
She was brought to the emergency room the following morning because of swelling of her hand. She was taken immediately to the operating room for compartment release. A: Volar hand prior to fasciotomy. B: Dorsal hand prior to fasciotomy. C: Volar release. D: Dorsal release. E: Finger flexion at 6 months. F: Finger extension at 6 months.
(Courtesy of Dr. M. Stevanovic.)
She was brought to the emergency room the following morning because of swelling of her hand. She was taken immediately to the operating room for compartment release. A: Volar hand prior to fasciotomy. B: Dorsal hand prior to fasciotomy. C: Volar release. D: Dorsal release. E: Finger flexion at 6 months. F: Finger extension at 6 months.
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Dorsal Release

The dorsal interosseous muscles (and volar interosseous muscles) are decompressed through dorsal incisions between the second and third metacarpals and the fourth and fifth metacarpals. The first dorsal interosseous muscle is decompressed through an incision placed in the first dorsal web space. The dorsal fascia of the adductor pollicis can also be released through this incision (Fig. 6-12A, B). 

Fingers

Tense swollen fingers can result in skin and subcutaneous tissue necrosis. The tight fibers of Cleland and Grayson's ligaments can compress and obstruct the digital arteries. Dermotomy of all involved fingers reduces the risk of necrosis of the skin and possible loss of the digit. Dermotomies should be done in the midaxial plane to prevent subsequent contracture. When possible, the dermotomy should be performed on the side that will cause the least amount of scar irritation. The preferred locations for finger and thumb dermotomies are shown in Figure 6-8AD

Postoperative

All surgical incisions are left open. We do not like the use of retention sutures in children. Even if there is minimal swelling of the muscle(s) during the primary release, muscle swelling will usually increase after perfusion has improved. If nerves and arteries are not exposed, a negative pressure wound dressing (e.g., VAC) can be used. If nerves or arteries are exposed, we prefer to use a moist gauze dressing. Dressing changes should be done in the operating room at 24 to 48 hours. Partial delayed primary wound closure can be performed at that time if swelling is decreased and/or to provide coverage over open neurovascular structures. Definitive wound closure should be performed only after swelling has decreased. In the hand, only the incision for the carpal tunnel release should be considered for delayed primary wound closure. The other palmar and dorsal incisions as well as the dermotomy incisions will close quickly healing by secondary intention. If the skin cannot be closed without tension, then split thickness skin grafting with or without dermal substitutes should be used. 
Therapy should be started immediately postoperatively to maintain maximum active and passive range of motion of the fingers. Splinting should be done as long as needed for soft tissue stabilization or for treatment of other associated injuries. Therapy may need to be temporarily discontinued during healing of skin grafts, but should be resumed as soon as tissue healing allows. Once the soft tissues are adequately healed, we continue nighttime splinting to prevent contractures of the wrist and fingers. Splinting is continued until scars and soft tissues are mature and supple. 

Established Contracture (Volkmann's)

Treatment of established Volkmann contracture depends on the severity of the contracture and neurologic deficits and the resultant functional losses. The classification system of Tsuge provides some guidance in establishing a treatment algorithm. However, each patient has unique deficits and needs. Reconstruction should take into consideration their deficits, residual motor and sensory function, and the patient's needs. Surgical treatment should not be undertaken before soft tissue equilibrium is present. 

Nonoperative Management

Nonoperative management should be instituted early in most cases of established Volkmann contracture. In children, there may be more recovery of nerve and muscle function over time than in adults, and we do not advocate immediate surgical intervention. A formal program of splinting and therapy can improve the outcome of later surgical intervention and may result in less extensive surgical corrections. Therapy should be directed toward maintenance of passive joint motion, preservation and strengthening of remaining muscle function, and correction of deformity through a program of splinting. We prefer the use of static progressive splinting or serial casting for fixed contractures of the wrist, fingers, and thumb web space. Mild contractures with minimal to no nerve involvement can often be treated only with a comprehensive program of hand therapy and rehabilitation. For moderate to severe involvement where surgery is anticipated, therapy is indicated only as long as necessary to achieve supple passive motion of the fingers. Preoperative therapy is also helpful in establishing a good patient and parent rapport with the therapist and in gaining an understanding of the postsurgical therapy program. 

Operative Treatment

A variety of surgical procedures have been used to treat Volkmann ischemic contracture. These have included both bone and soft tissue management. 
Bone Reconstruction: Shortening procedures including shortening osteotomy of the radius and ulna and proximal row carpectomy have been used to match the skeletal length to the shortened fibrotic muscle.14,33 Generally, we do not like shortening procedures in children, because the forearm is already relatively shortened by the initial ischemic insult to the bone and growth plates. Further, the principal contracture is usually on the flexor surface. Shortening the forearm indiscriminately lengthens the muscle resting length of both the flexor and extensor muscles, neglecting the predominant involvement of the contracture within the flexor compartment. Bony reconstructive procedures for long-standing contractures or for distal reconstruction required for neurologic injury include wrist fusion, trapeziometacarpal joint fusion, or thumb metacarpophalangeal joint fusion, which should be done after skeletal maturity. These may be considered in conjunction with some of the soft tissue procedures listed below. 
Soft Tissue Procedures: Soft tissue procedures have included excision of the infarcted muscle, fractional or z-lengthening of the affected muscles, muscle sliding operations (flexor origin muscle slide), neurolysis, tendon transfers, and functional free tissue transfers, as well as combinations of the above procedures.7,8,10,14,16,19,22,23,32,37,46,48,49,55 Excision of scarred fibrotic nerves without distal function followed by nerve grafting has been described to try and establish some protective sensation in the hand.18 Fixed contractures of the joints can be addressed with soft tissue release including capsulectomy and collateral ligament recession or excision, depending on the joints involved. 

Author's Preferred Methods

Our preferred methods of treatment depend on the general classification of severity of contracture, individualized to the patient presentation. 
Mild (localized) Type (Deep flexor compartment without neurologic deficit): For mild contractures which have failed to respond to nonsurgical management, our preferred treatment is a muscle sliding operation initially described by Page and subsequently used and endorsed by several others.23,26,29,35,37,39,48,49 We have found this procedure effective as long as there is clinically good finger flexion. We do not combine this procedure with infarct excision, nor have we found it necessary to release the distal insertion of the pronator teres to correct pronation contracture.23,49 
We differ with Tsuge in our surgical incision and favor the technique initially described by Page (Fig. 6-13). The surgical incision begins on the ulnar distal arm and continues along the ulnar border of the forearm all the way to the wrist. The ulnar nerve is identified and mobilized out of the cubital tunnel and for several centimeters proximal to the medial epicondyle. Three to four centimeters of intermuscular septum is excised. The flexor pronator mass is elevated off of the medial epicondyle, taking care to preserve the medial collateral ligament and elbow joint capsule. The origins of the flexor carpi ulnaris, flexor digitorum longus, and flexor digitorum superficialis are carefully mobilized off of the ulna and interosseous membrane. The dissection is carried out above the periosteum toward the radius. The common interosseous artery arises as a branch of the ulnar artery, crossing the flexor digitorum profundus. Here it bifurcates into the anterior and posterior interosseous arteries. The posterior interosseous artery crosses to the posterior compartment at the proximal edge of the interosseous membrane, and can be easily injured in this area. As this is the dominant blood supply to the extensor compartment, it is important to protect this branch (Fig. 6-14A, B). Working toward the radius, the origin of the flexor pollicis longus is released from proximal to distal. Throughout the procedure, the wrist and fingers are manipulated to check whether the contracture is improving and to help localize where there is still tightness within the muscle origin. The dissection must often be carried down to the level of the wrist to release adhesions between the flexor tendons and pronator quadratus before full correction is achieved. If necessary, the carpal tunnel should be opened and tendon adhesions released in this area as well. Slight under correction, which can be addressed by postoperative splinting and rehabilitation may decrease the reduction in muscle power resulting from the muscle slide. When a pronation contracture is present and not corrected by the release of the flexor–pronator origin, we release the pronator quadratus from the distal ulna. Even with a complete release of both pronators and dorsal distal radioulnar joint capsule, complete correction of the pronation deformity may not be possible because of fibrosis and contracture of the interosseous membrane. At the completion of the muscle slide, the ulnar nerve is transposed to an anterior subcutaneous position. The hand is splinted and subsequently casted in a position of forearm supination, wrist and finger extension. We continue this immobilization for a period of 6 weeks to allow the flexor–pronator origin to heal adequately to its new origin (Fig. 6-15). 
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Figure 6-13
Extended ulnar incision.
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Figure 6-14
Flexor slide with muscle elevation and showing the posterior interosseous artery branching from the common interosseous artery.
A: Diagram. B: Clinical photo.
A: Diagram. B: Clinical photo.
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Figure 6-15
This 7-year-old boy sustained an SCH fracture after a fall from a tree.
 
He was treated with closed reduction and pinning. He presented 1 year after his injury with inability to extend his fingers and thumb. A: Preoperative maximum extension. B: Preoperative maximum flexion. C: Extended ulnar incision. D: Intraoperative flexor slide. At the completion of the flexor slide, the patient has full extension of the elbow, wrist, and fingers. E: 1-year postoperative extension. F: 1-year postoperative flexion.
He was treated with closed reduction and pinning. He presented 1 year after his injury with inability to extend his fingers and thumb. A: Preoperative maximum extension. B: Preoperative maximum flexion. C: Extended ulnar incision. D: Intraoperative flexor slide. At the completion of the flexor slide, the patient has full extension of the elbow, wrist, and fingers. E: 1-year postoperative extension. F: 1-year postoperative flexion.
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Figure 6-15
This 7-year-old boy sustained an SCH fracture after a fall from a tree.
He was treated with closed reduction and pinning. He presented 1 year after his injury with inability to extend his fingers and thumb. A: Preoperative maximum extension. B: Preoperative maximum flexion. C: Extended ulnar incision. D: Intraoperative flexor slide. At the completion of the flexor slide, the patient has full extension of the elbow, wrist, and fingers. E: 1-year postoperative extension. F: 1-year postoperative flexion.
He was treated with closed reduction and pinning. He presented 1 year after his injury with inability to extend his fingers and thumb. A: Preoperative maximum extension. B: Preoperative maximum flexion. C: Extended ulnar incision. D: Intraoperative flexor slide. At the completion of the flexor slide, the patient has full extension of the elbow, wrist, and fingers. E: 1-year postoperative extension. F: 1-year postoperative flexion.
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A limited flexor slide may be done for mild deformity, affecting only a portion of the flexor digitorum profundus. In this case, the surgical incision is the same; however, the flexor pronator mass does not have to be released from the medial epicondyle, and the ulnar nerve does not have to be mobilized and transposed. We do not usually perform a neurolysis, because by definition of the mild type, there is little to no nerve involvement. We think that this surgical approach limits potential scarring and vascular compromise to the remaining muscles and nerves in the flexor compartment, and that the superficial veins are better preserved in the subcutaneous tissue. 
Moderate Type (Deep and superficial flexor compartment with neurologic deficit): For moderate deformity, we still prefer the muscle slide operation to correct the tightness of the flexors, provided that there is still adequate remaining strength in the flexors. Since neurologic impairment is characteristic of the moderate injury, we combine the flexor slide with neurolysis of both the median and ulnar nerves. A separate incision to release the carpal tunnel may also be done. Depending on the functional deficits, tendon transfer can be combined with flexor slide, usually as a staged procedure. 
Reconstruction of Thumb Function: Our preferred transfers for thumb flexion is to use brachioradialis or extensor carpi radialis longus to the flexor pollicis longus. Extensor indicis proprius is used for thumb opposition. 
Reconstruction of Finger Flexion: When the finger flexors are very weak or absent, a functional free muscle transfer may produce a better functional result than tendon transfers. However, if functional free muscle transfer is not an option, tendon transfers include: Biceps brachii elongated with autograft (fascia lata or superficialis tendon) to the flexor digitorum profundus. Extensor carpi radialis longus, brachioradialis, extensor carpi ulnaris, and extensor indicis proprius can also be used as donor muscles for reconstruction of finger flexion. These donor muscles do not have sufficient excursion to match the flexor muscles, but in the absence of other options, they can provide adequate improvement in grasp. 
Nerve Reconstruction: When sensory impairment is severe and there has been no recovery, the nerve should be carefully evaluated at surgery. If there is a densely scarred atrophic nerve, resection of the nerve to healthy appearing fascicles followed by sural nerve graft reconstruction may restore protective sensation to the hand. 
Severe Type (superficial and deep flexor compartments, extensor compartment, and severe neurologic deficits): Severe type contractures are best treated with functional free muscle transfers.7,8,19,22,55 The donor vessels are usually either the radial or anterior interosseous artery as an end-to-end anastomosis, or end-to-side to the brachial artery. The donor motor nerve is the anterior interosseous, which should be resected back to healthy appearing fascicles. Our preference for the donor muscle is the gracilis. Appropriate marking of the muscle resting length and establishing a strong muscle origin and insertion are critical to achieving good functional results.45 Zuker has described using separate motor fascicles of the gracilis to restore independent flexor digitorum profundus and flexor pollicis longus motor function.55 
For severe type contractures with extensive involvement of the extensor compartment, a double-free muscle transfer should be considered. As with the moderate type, tendon transfer, nerve graft reconstruction, and late osseous reconstructive procedures may improve final functional outcomes. 
Postoperative: Both operative and nonoperative treatment requires splinting and therapy (whether formal or informal) through skeletal maturity. 

Outcomes

The duration of elevated tissue pressures before definitive surgical decompression may be the most important factor in determining outcome. In adults, prolonged ischemic insult to compartment musculature greater than 8 hours increases the risk of permanent sequelae.12 Favorable outcomes can be expected if decompression is accomplished in less than 8 to 12 hours.24 Full functional recovery within 6 months has been reported with timely management of compartment syndrome in the pediatric population.2 The development of compartment syndrome does not seem to delay fracture healing. 
Complications associated with compartment syndrome include functional muscle loss, contracture, neurologic deficit (both motor and sensory distal to the level of injury), cosmetic deformity, growth arrest, and infection. Less commonly, loss of limb, rhabdomyolysis, multiorgan system failure, and death can be seen, especially in the setting of crush injury with severe large volume muscle necrosis. 
Permanent and disabling outcomes are a real and significant risk of compartment syndrome. Early recognition of the diagnosis and expeditious treatment may minimize long-term functional disability; however, even promptly treated compartment syndrome can have permanent residual deficits.5,13,28 
Outcomes following Volkmann contracture in the upper extremity are difficult to assess. Studies are limited by small numbers of patients, great variability in initial presentations, use of varied surgical techniques, and difficulty in compliance with the long-term follow-up necessary to track patients through skeletal maturity. Ultee and Hovius attempted to provide some information regarding outcomes. They found that all patients who had developed the contracture during childhood had a relatively shortened extremity. Substantial improvements in hand function were noted in those patients who underwent functional free muscle transfer. Tendon lengthening alone often resulted in recurrence of contracture. Finally, in patients who had sufficient remaining muscle, procedures which combined infarct excision, tenolysis, neurolysis, and tendon transfer when necessary produced good hand function.50 Sundararaj and Mani noted improvement in sensory function in conjunction with neurolysis. Additional procedures were done simultaneously, and little analysis of outcomes of those other procedures was given.47 In our experience, mild and moderate contractures can have significant functional improvement following flexor muscle slide and nerve reconstruction when indicated. Normal function is not anticipated, but a hand with protective sensation and functional grasp can often be achieved. Functional free muscle outcomes can also restore gross grasp and have a much better outcome in patients with good intrinsic function. 

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