Review Question - QID 109585

This patient is presenting with pain and paresthesias of an arm that was casted for a supracondylar fracture. These are highly specific signs of compartment syndrome and should be managed with fasciotomy (or at a minimum strict monitoring).

Among the most common pediatric fractures is a supracondylar fracture, which presents with the classic radiographic finding of the posterior fat pad sign. Damage to the median/radial nerve and brachial artery is possible and patients should have an injury to these structures ruled out with a physical exam/Doppler ultrasound. When casting these patients, they must be monitored for the feared complication of compartment syndrome, which can present with the 6 P's (Pain, Pallor, Poikilothermia, Paresthesias, Pulselessness, and Paralysis). If these symptoms are present in a patient with a cast, even in the setting of palpable pulses, non-tense compartments, and normal compartment pressures, you must still treat for compartment syndrome. The treatment of choice is either frequent monitoring (if there are not enough specific symptoms to make the diagnosis) or fasciotomy.

Armstrong et al. review the evidence regarding the risk factors for the development of compartment syndrome in patients with a supracondylar humerus fracture. They discuss that a vascular procedure and a concurrent forearm fracture are major risk factors. They recommend being vigilant for compartment syndrome given that not all patients have risk factors.

Figure/Illustration A is a radiograph demonstrating a fat pad sign (red circle). This finding is commonly seen in a supracondylar fracture.

Incorrect Answers:
Answer 2: Ibuprofen will manage the patient's symptoms and mask the underlying compartment syndrome. Without definitive treatment, irreversible damage could occur. Patients with a high clinical suspicion for compartment syndrome should undergo fasciotomy.

Answer 3: Reassurance is inappropriate management of a patient suffering from compartment syndrome. Severe and irreversible damage could occur without treatment. Patients may have a falsely normal compartment pressure.

Answer 4: Recasting with additional padding ignores the possibility of compartment syndrome in this patient. At a minimum, this patient should be frequently monitored and closely observed to make sure the patient does not develop a florid compartment syndrome.

Answer 5: A sling is not appropriate management of a supracondylar fracture. This patient should first have their impending compartment syndrome addressed and then be treated with definitive closed or open reduction.

Bullet Summary:
Compartment syndrome presents with pain with passive stretch and is managed with fasciotomy.