Keywords
compartment syndrome - iatrogenic - compressive dressing - burns - children
New Insights and the Importance for the Pediatric Surgeon
Iatrogenic compartment syndrome can lead to severe sequelae; it is infrequent, but
preventable. Small children are at higher risk due to the difficulty of noncompliance.
Pediatric surgeons must be aware of its etiology to prevent harm of their patients.
Introduction
Acute compartment syndrome is a surgical emergency that can severely compromise the
circulation, function, and even viability of an extremity. It occurs when an increase
in the pressure within any closed, fixed compartment (defined by myofascial elements
or bone) exceeds the perfusion pressure of the tissue, leading to ischemia and necrosis.[1] Most cases of acute extremity compartment syndrome develop after severe injuries
such as fractures, but they can also occur after lesser injuries or, less frequently,
they can be iatrogenic, secondary to tight dressings or tightly applied splints and
casts, with the same terrible consequences.[2]
We report a severe case of compartment syndrome due to a compressive burn dressing.
Case Report
An otherwise healthy 2-year-old girl arrived at her local health center with a contact
burn with a hot iron several minutes before. She presented a noncircumferential, superficial
partial-thickness burn on the dorsum of the mid phalanx of the second finger of her
right hand. A compressive dressing was applied solely to the affected finger. Forty-eight
hours afterward, the patient presented at the emergency room with severe pain of the
finger. After removal of the dressing, a circumferential constrictive eschar was observed
at the base of the finger, secondary to ischemia due to the compressive dressing,
which generated a significant compartment syndrome with severe vascular compromise
of the finger ([Fig. 1A]). Emergent bilateral escharotomies were performed, with immediate recovery of distal
perfusion ([Fig. 1B]). One week afterward, the patient underwent surgical debridement of the burn on
the dorsum of her finger and escharectomy of the ischemic eschar at the base. The
lesions were covered with split-thickness skin grafts, the donor site being the ipsilateral
arm ([Fig. 2A]). As soon as the graft healed, the patient was started on splinting and physical
therapy. However, after 3 months, the patient presented with a palmar contracture
of the digit that limited full extension of the finger ([Fig. 2B]). The contracture was surgically released and the resulting skin defect was covered
with full-thickness skin graft (donor site: contralateral groin). At 8 months follow-up,
and after intense splinting and physical therapy, the patient shows a normal function,
achieving complete extension of the finger, with a mature, asymptomatic, flat scar
([Fig. 2C] and [D]).
Fig. 1 (A) Ischemic circumferential constrictive eschar at the base of the finger (black arrow),
secondary to compressive dressing, with severe vascular compromise of the finger.
Arrowhead: burn lesion. (B) Immediate recovery of distal perfusion after emergent bilateral escharotomies (black
arrow) were performed. Arrowhead: debrided burn.
Fig. 2 Treatment of the sequelae. (A) Immediate postoperative result after surgical debridement of the burn on the dorsum
of the finger and escharectomy of the ischemic eschar at the base and grafting with
partial-thickness skin grafts. (B) Severe palmar contracture of the digit at 3 months follow-up. (C) Dorsum of hand at 8 months follow-up, after surgically releasing the contracture
and grafting with full-thickness skin graft. (D) Palm of hand.
Discussion
Acute compartment syndrome is a devastating diagnosis that can lead to severe sequelae,
such as the loss of an extremity or body segment.[3]
Any pathologic condition that increases the volume inside a closed compartment (intrinsic
causes, such as bleeding or edema after a fracture) or limits the external dilation
of the compartment (extrinsic causes, such as burns or tight dressings) will increase
the internal pressure of the compartment, potentially leading to acute compartment
syndrome, with tissue necrosis.[4] Intrinsic causes, such as fractures or severe crush injuries, are by far the most
frequent cause of acute compartment syndrome. Infrequently, iatrogenic causes like
compressive dressings or tight splints and casts can also produce severe damage.[5] The case of acute compartment syndrome we present in this article is distinctly
of iatrogenic origin, consequence of a negligent act. The application of an excessively
tight circumferential dressing around the base of the finger produced a local necrosis
of the skin, which behaved like a circumferential third-degree burn, restraining the
dilation of the finger and thus hindering appropriate perfusion.
All cases of iatrogenic compartment syndrome are potentially preventable and easy
to avoid if health professionals are adequately trained and provide care to their
best of their knowledge, being extremely cautious in all their actions.[6] With regard to the presented case, all damage could have been avoided if a noncompressive,
noncircumferential dressing had been applied and the tip of the finger had been left
exposed to monitor for possible vascular compromise.
Although this case is the consequence of a neglectful act, it is nonetheless interesting
to point out that the patient presented other risk factors that might have favored
the development of the compartment syndrome. First, the patient sustained a thermal
burn. This lesion was certainly not the cause of the compartment syndrome, for it
was neither circumferential nor deep, but it must have triggered a local inflammatory
response that might have contributed to the onset or aggravation of the compartment
syndrome.[7] Second, small children are especially vulnerable to iatrogenic complications, for
they are frequently unable to cooperate due to their immature cognitive abilities
and their limited verbal capacity sometimes precludes adequate communication.[8] For a start, it can be very challenging to apply an adequate dressing on a toddler,
for the patient will not collaborate. Also, some alarm symptoms (such as intense pain)
might be overlooked in young children due to their inability to provide clinical information,
resulting in delays in diagnosis and treatment. In any case, care providers that frequently
take care of burns and/or children should be appropriately qualified and be aware
of the particular idiosyncrasy of minors.
Cases such as the one we present here should result in education and training of health
personnel at all levels, with a very especial emphasis on prevention of iatrogenic
complications; practitioners and nursing staff should be aware of the very severe
consequences their neglectful actions may have on patients. As health-care providers,
we have a responsibility to provide the best possible medical care.
Conclusion
Iatrogenic compartment syndrome is an infrequent but preventable cause of possible
severe damages, such as the loss of an extremity or body segment. It is fundamental
that health professionals are aware of its etiologies and risk factors and take utmost
care in all their actions, to avoid negligent acts that could lead to severe or permanent
damage to patients.
