Pediatric acute compartment syndrome due to surgical positioning: a case report

Abstract

Pediatric acute compartment syndrome from surgical positioning may be difficult to recognize. Increasing anxiety and analgesic requirements can suggest developing compartment syndrome. We present a case of compartment syndrome after a non-orthopedic surgery.

A five year-old previously healthy male underwent resection for a right-sided neuroblastoma arising from the adrenal gland. Before incision, a single-shot right-sided paravertebral block was administered with 0.5% bupivacaine. The surgery lasted nine hours with the patient positioned with his left side down.

Post-operatively, morphine was ordered for analgesia once the paravertebral block started to wear off. In the ensuing days, the patient had abdominal pain but also increasing pain in the left leg requiring higher amounts of opioids. His left leg was edematous and ruled out for thrombosis on post-operative day two. On post-operative day three, orthopedic surgery was consulted, and high pressures were noted in the leg. Creatinine phosphokinase was elevated to 2217 units/liter. The patient underwent an emergent decompressive fasciotomy. Muscle injury was found in the lower leg, although no muscle or nerve death was noted.

Following the fasciotomy, the patient remained hospitalized for wound care and was discharged after two weeks with no pain or edema in the leg.

DISCUSSION

Acute compartment syndrome causes decreased perfusion leading to nerve and muscle injury. Risk factors include prolonged direct pressure on the compartment, venous obstruction, bleeding or other causes of inappropriate fluid accumulation. Basic science studies have shown that ischemia begins after four hours of elevated compartment pressure, and cell death occurs after eight hours.¹

Although acute compartment syndrome in both adults and children is usually due to trauma², our patient did not have a preceding injury and likely suffered from compartment syndrome due to laying on his left side for a long surgery. Compartment syndrome due to positioning is more likely in surgeries that last longer than five hours. In the pediatric population, it is more likely in adolescents than in young children.² Although occurring more commonly in the dorsal lithotomy position, acute compartment syndrome in the lateral decubitus position may result from increased pressure on the down leg and venous obstruction from hip flexion^{1, 2}. Our patient also was positioned with a bean bag, possibly applying undue pressure and causing venous return obstruction.

Diagnosis and treatment of pediatric acute compartment syndrome is often delayed especially in non-trauma related cases. Lin et al showed in a systemic review that the time from injury to fasciotomy for pediatric compartment syndrome was 25.5 hours for patients with fractures compared to 36.2 hours for those without fractures³. Classical criteria for diagnosis in adults such as the five P’s (pain, paresthesia, paralysis, pallor, pulselessness) are often not reliable in young children. Instead, increasing anxiety and analgesic requirements may be more appropriate signs of pediatric compartment syndrome ^{2, 3}. Increasing opioid usage and pain remote from the surgical site were clues in our patient, yet compartment syndrome was only suspected after a deep vein thrombosis was ruled out as the source of symptoms.

Concern that regional anesthesia may mask pain and delay the diagnosis of compartment syndrome is sometimes noted in orthopedic surgery journals.^{1, 2} However, the evidence for this in the literature is inconclusive and based mostly on case reports. Oftentimes other clues were present indicating developing compartment syndrome.⁴ In a review of 12 cases of pediatric compartment syndrome with epidural analgesia, Johnson did not find that epidurals delayed diagnoses but did recommend avoiding dense blocks in patients at risk for compartment syndrome.⁵

Despite delayed diagnosis and fasciotomy, children often have better long-term outcomes compared to adults. For adults, fasciotomies more than 24 hours after the injury may have worse outcomes than forgoing surgery altogether. Conversely, the rate of long-term neurological deficits in children is low. Lin found that 88 percent of children who underwent fasciotomies more than 48 hours after injury had full recovery. Additionally, no significant difference in recovery was found between fasciotomies within 48 hours and after 48 hours.³

In summary, this is a rare case of non-trauma related pediatric acute compartment syndrome for a surgical patient in the lateral decubitus position. The diagnosis should be suspected for children who have increasing analgesic requirements in addition to signs and symptoms in an area remote from the surgical site. Masking of symptoms by regional anesthesia is unlikely at low concentrations of local anesthetics. Importantly, surgical decompression often results in excellent long-term outcomes despite a delay in diagnosis.

LEARNING POINTS.

1. The risk of pediatric acute compartment syndrome from surgical positioning is greater in surgeries longer than five hours in duration and in adolescents.

2. Increasing anxiety and analgesic requirements may indicate developing pediatric compartment syndrome.

3. The strength of evidence for regional anesthesia masking the symptoms of compartment syndrome is currently low, especially with low concentrations of local anesthetic.