Osteofascial compartment syndrome (OCS) is a serious emergency condition in pediatric orthopedics. If not treated properly, it is liable to lead to ischemic muscle contracture (Volkmann’s contracture) with a high rate of disability. OCS not only affects the body functions but also significantly influences the psychological health of the pediatric patients. [1–4] Due to impacts from heavy objects, crush injuries or long-term compression (overtight or prolonged fixation by small splints or plaster casts), the removal of the pressure causes blood reperfusion and results in the bleeding and reactive swelling of injured tissues (mainly muscular tissues), which leads to the increased volume of contents in intermuscular septa followed by increased pressures and acute OCS. Acute OCS can cause rhabdomyolysis and acute muscular atrophy, disseminated intravascular coagulation, electrolyte disturbance, renal failure, and other complications and even death in some severe cases.
The typical symptoms and physical signs of OCS can usually be described clinically as the "5P" symptoms: namely, Pain or from pain to painless, pallor, pulselessness, paralysis, and paresthesia. However, when the injured limbs show the typical "5P" symptoms, the best time for treatment has often been missed, which may result in serious consequences such as physical disability and even amputations. [13] Severe pain not consistent with the degree of injuries, passive stretching pains in the limbs, as well as sensory loss within the region where the injured nerves are distributed have long been considered as important clinical signs indicating OCS. In the present study, OCS was diagnosed based on the presence of evident post-traumatic swelling and pain, especially passive stretching pain. In other clinical retrospective studies, it has been found that 100% of the subjects suffered passive stretching pains in the limbs and 60% experienced paresthesia.[14] OCS can be diagnosed if the osteofascial compartment pressure is higher than 30 mmHg in the patients with a history of trauma and a high degree of local swelling in the limbs.[13, 15] However, pediatric patients often have poor descriptive capability, do not cooperate during physical examination, and cannot accurately express their sensation. In addition, pressure measuring devices are not equipped in the hospitals in underdeveloped areas, and pressure measurement is inaccurate in some cases, leading to limited application of pressure measure in the diagnosis of OCS.[16] Therefore, health care providers should carefully observe the conditions of the patients and be vigilant for the occurrence of this disease.[3, 13, 17]
Even though conservative treatments, such as mannitol, can be applied for this disease at an early stage, the only timely and effective treatment for this disease is effective decompression therapy prior to the aggravation of the condition when the ischemic changes in the muscular tissues are still reversible. [1–3] Currently, the complete incision for osteofascial compartment decompression at an early stage is the only way to effectively prevent ischemic necrosis of the muscles and nerves. Incision decompression should be performed immediately once the diagnosis is confirmed and short-term conservative treatments are not effective. Early incision is preferred when compared with delayed treatment. [18, 19] The gold standards for the treatment of OCS are early diagnosis and emergent surgical decompression through fasciotomy within 8 hours. Therefore, the treatment for OCS is focused on early decompression but is not unlimited conservative treatment only. [20, 21] In the present study, incision decompression was immediately performed for all the patients who did not show improvement 2–4 hours after conservative therapy, which produced significant therapeutic effects.
The choice of surgical incision size has been controversial. Large incisions are traditionally considered to be more conducive to the removal of necrotic tissue and complete decompression. However, large incisions are prone to complications of infection and prolonged periods of dressing changes. Moreover, second-phase wound sutures, even dermoplasty, are required for wound healing, which leaves visible scars that affect the patient’s appearance. [5–6] Thus, we prefer multiple small incisions for decompression. Incision decompression was performed in the areas with marked swelling and elevated tension, which on one hand provides complete and effective decompression and on the other hand allows for closed reduction and external fixation of fractures and avoids secondary surgeries. In the present study, the results suggested that fasciotomy via multiple small skin incisions was simple and fast operation procedure with less trauma, shorter operation time, without space restrictions, and was suitable for emergency treatment and surgeries in remote mountainous areas and field sites. Moreover, multiple small skin incisions are associated with less intraoperative blood loss, good postoperative recovery of local skin, little impact on the appearance, easier second-phase wound healing, and low infection rate.
However, small incision has its limitations. The multiple small skin incisions can only provide timely and effective decompression for osteofascial compartment, but cannot completely clear the ischemic necrotic tissues and repair the injured blood vessels or nerves. Therefore, fasciotomy via multiple small skin incisions is only recommended for early OCS without neurovascular injury.