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Physicians Should Be Vigilant for Compartment Syndrome After Pediatric Elbow Injury
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Posted on: 09/18/2008
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Dislocated elbows are not an uncommon injury in children. Between 3 percent to 6 percent arm injuries in children are traumatic elbow dislocations, caused by an injury. Up to 41 percent of the dislocations are also part of other injuries around the elbow and are usually caused by a fall on to an outstretched arm and hand. As with most injuries, complications can happen and one serious one after a dislocated elbow and fractures of the lower arm bones, the ulna and the radius is called compartment syndrome.
Compartment syndrome happens when swelling and pressure within the muscles begin to build. But, the way the body is built, there is no room for the swelling to go and the pressure continues to build on the muscles, blood vessels and nerves. As this pressure increases, the blood can't flow to the muscles and this causes death to cells in the muscles and nerves.
One type of elbow dislocation and injury is rare but it can result in compartment syndrome. This is the osteochondral fracture and it occurs in between 4 percent and 7 percent of elbow fractures. With this type of fracture, the cartilage that covers the end of a bone in a joint and creates bone or cartilage fragments. It is possible for doctors to miss this diagnosis as it is such a rare injury. Sometimes, when the elbow is dislocated, it can move back into place on its own right away and in these cases, it may be even more difficult for a doctor to see the fractures.
The authors of this article discuss a case of a four-year-old boy who had fallen off a swing set five days before they saw him. He had pain in the right elbow and wasn't able to extend, or stretch out, his fingers of his right hand. The day he had fallen, he was seen in an emergency room and was diagnosed with having an olecranon fracture. This is a fracture of the very tip of the elbow. He was given a cast that kept his arm bent at 90 degrees. After 48 hours, he was brought back to the emergency room because of unrelieved pain. The cast was removed and reapplied. Three days later, he was brought to the institution where the authors were because the boy still had pain and was having difficulty moving his fingers.
The doctors examined the elbow and found that there was a tense swelling in the forearm and there was ecchymosis, a type of bruising that shows that blood is escaping into the body tissues. The boy could move his elbow a bit, with pain, but stretching his fingers caused excruciating pain. X-rays showed a bit of osteochondrial bone and a computed tomography image (CT scan) confirmed that there was a speck of bone where it shouldn't be.
Surgeons operated on the arm to remove the pressure that the bone speck was causing, debris was removed as was any part of the muscle that was no longer usable. After the surgery, the boy was casted for five weeks and then he used a hinged brace for another week.
One year after the surgery, the boy had no pain in the elbow and good elbow movement.
The authors concluded with an emphasis of the importance of careful clinical and x-ray examination of children who have elbow injuries. They also wrote that they recommend "more surveillance for all children who revisit the hospital within 48 hours following this sort of injury."
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References:
Durga Nagaraju Kowtharapu, MD et al. Osteochondral Flap Avulsion Fracture in a Child with Forearm Compartment Syndrome. In Orthopedics. August 2008. Vol. 31:805.
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