Cutting edge Orthopedics

8 • CUTTING EDGE - ORTHOPEDICS of 0.1–0.5% [38, 39]. The rate of compartment syndrome increases to 7% if there is an ipsilateral forearm fracture [24]. Additionally, the risk of compartment syndrome is higher in patients who need vascular repair for a dysvascular limb [40]. The typical signs of compartment syndrome in an adult (pain, pallor, pulselessness, paresthesia, and paralysis) are not reliable in children [41]. Bae and colleagues (2011) assessed children with compartment syndrome and determined that an increasing analgesic requirement was the most sensitive indicator of compartment syndrome in pediatric patients [41]. Building from these findings, the “three A’s” of pediatric compartment syndrome have been proposed: analgesia, anxiety, and agitation [9, 14, 42]. Clinical Presentation History Patients who present with supracondylar humerus fractures, or their caretakers, typically report a history of a fall, either on an outstretched hand or directly onto the elbow [8, 34]. Children frequently report pain and swelling about the elbow, which may extend distally into the forearm, wrist, and hand [9, 19]. Patients also typically report limited mobility of at least the elbow [19] and sometimes the entire limb [9]. Physical Exam Physical examination of pediatric patients requires the examiner to be flexible and adaptable to obtain a thorough physical exam. Observation is key and allows the examiner to gain insight regarding the location of the injury and neurovascular status [9]. Additionally, modifying the traditional physical exam progression is recommended. Beginning the exam with simple assess- ments that do not cause any additional pain, such as checking pulses or sensation, may help gain the child’s trust. Reserving assessments that may intensify anxiety or pain, such as palpation, for the end of the exam will allow the examiner to gather all other necessary information first. Observation Visual inspection of the limb to determine the extent of any swelling, ecchymosis, abrasions, and skin breaks often allows the examiner to identify the location of the injury and, perhaps, narrow the differential diagnosis. Skin puckering and ecchymosis in the antecubital fossa indicate more extensive soft tissue injury due to the proximal fracture fragment piercing the brachialis muscle (Fig. 8) [5, 8, 30]. Bleeding wounds are suggestive of an open fracture [5]. Additionally, comparing the color and appearance of the skin to the uninjured side indicates whether the limb is adequately perfused (pink) or dysvascular (white) [9]. Lastly, any active motion should be carefully noted to assist with the neurologic assessment [9].