Orthopedic Involvement in Viper Bitte in Children in Greece. A Single Center Experience

doi:10.21203/rs.3.rs-4883393/v1

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Orthopedic Involvement in Viper Bitte in Children in Greece. A Single Center Experience

https://doi.org/10.21203/rs.3.rs-4883393/v1

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Purpose: Venomous snakes species found in `Greece belong to the Viperidae family. Their bitte can cause local and systemic symptoms. Orthopedic involvement is important in prompt recognition and treatment of compartment syndrome. We present four pediatric cases of viper envenomation, two of which developed compartment syndrome.

Methods: From 2021- 2024 four pediatric patients were treated in our institution because of viper bitte in the hand. The patient’s age were 10 months, 2, 4 and 11 years. Primary symptoms were local oedema, pain, ecchymosis and drowsiness and they were hospitalized in the Intensive Care Unit. They all received symptomatic and supportive care and antivenom serum was administered in all patients.

Results: Two of the children developed compartment syndrome and received emergency fasciotomies. The 2-year-old patient received hand fasciotomies. The 11-year-old patient developed hand paresthesia in the distribution of the median nerve and hand, forearm and humerus compartments were released. Skin incisions were sutured after 3 days. There were no complications and normal limb function was preserved. Of the children that did not need fasciotomies, it was notable that the administration of antivenom doses seemed to halt the progression of the oedema of the extremity.

Conclusion: Viper bitte is a rare medical emergency and treatment includes a multidisciplinary approach. Early involvement of orthopedic surgeons is paramount for the preservation of normal limb function and in order to avoid serious systemic complications that may occur from muscle ischemia and necrosis.

viper bitte

Greece

pediatric

compartment syndrome

Viper bitte in Greece are a rare cause of death but may be complicated with compartment syndrome.

What is new

Supportive care and antivenom administration are of paramount importance but children seem to be sensitive in developing compartment syndrome. Extreme vigilance is advocated especially because clinical examination of young children is more demanding

There are 8 venomous snake species that can be found in Greece and the most common belong to the viperidae family. Vipera Ammodytes is considered the most dangerous with a highly cytotoxic and neurotoxic venom and can be found throughout the country. Montivipera xanthina (Ottoman viper) is the largest viper species found in the region, with highly toxic venom[1], [2]. Approximately 200 people are bitten every year but only 6 people died from 2000–2014 (Hellenic Statistical Authority-ELSTAT data). The most common symptoms include two symmetrical bite marks, pain, local oedema, ecchymosis, dizziness, nausea, vomiting and local lymph node enlargement[3]. Complications include blister formation of the skin due to the swelling, compartment syndrome, respiratory distress, palpitations and syncope[4]. The role of the orthopedic surgeon in this context, consist of the close assessment of the neurovascular status of the affected limb and the prompt treatment via surgical fasciotomies, in the event of development of compartment syndrome.

During the period 2021–2024 four children were treated in a third-grade public hospital due to venomous snake bitte. All children were bitten in their hand, had the two distinctive fang marks and the three youngest were bitten in their home environment. One attack took place in the home yard, one in a portable baby swimming pool, one in the child’s room and one in children’s camp. The youngest was 10 months old, a 2-year-old, a 4-year-old and the oldest was 11 years old. Presenting symptoms were pain, local swelling of the limb and drowsiness, without hemodynamic instability. The limb was immobilized with non-constrictive splinting, and they received supportive care with antibiotics, intravenous administration of fluids and electrolytes and were closely monitored in the Intensive Care Unit (ICU) Fig. 1. Antivenom serum was also administered under close observation with no adverse events. During their hospitalization two of the patients (the 2-year-old and the 11 year old child) gradually developed signs and symptoms of hand and forearm compartment syndrome and emergency fasciotomies were done. The decision was based on clinical signs of paresthesia in the median nerve distribution, excess oedema, extreme tension and pain in passive muscle stretching.

Surgical technique

Surgical release of the hand compartments included two dorsal incisions between the second and fourth metacarpal, one palmar in the thenar area, one in the hypothenar area and carpal tunnel release. The forearm compartments were released by one palmar and one dorsal incision. In one patient the palmar incision of the forearm was extended to the humerus, releasing lacertus fibrosus and the humeral compartments due to expansion of the swelling to the humerus as well. Only the incision for the carpal tunnel release was sutured on the index operation and the rest were left open. Subcutaneous tissue and muscles were bruised Fig. 2.

In the two cases, where fasciotomies were made, there was immediate relief from pain and the oedema and paresthesia subsided in three days. Skin incisions were sutured after three days uneventfully with no signs of infection. The oldest child during his hospitalization on the second day developed right hydrothorax and a drain was placed which was removed five days later. For the patients that did not require emergency fasciotomies, neurovascular status of the limb was assessed every hour on the first day. Because of their young age, the main clinical signs observed, were lack of pain in passive muscle stretching, good capillary refill and the gradual improvement of local oedema of the limb. Paresthesia could not be assessed because of their young age. Mean hospitalization time in the ICU was 3.2 days and all patients were later transferred to the pediatric department. Mean time to discharge was ten days. There were no major systemic complications apart from the child that developed hydrothorax. Of the children that did not require fasciotomies, it was notable that the administration of antivenom doses seemed to halt the progression of the local oedema Fig. 3.

Viper bitte in our region is not very uncommon. According to the Hellenic Statistical Agency in 2014 there were 48 patients that were treated for snake envenomation. Even though every year approximately 200 people get bitten from vipers there were only 6 deaths from 2000–2014. Snake venom is a complex mixture of proteins, polypeptides and bioactive molecules with various toxicity and pathophysiological effects. Snakes from the Viperidae family mainly contain venom with hematotoxic and cytotoxic effect[5]. There is no test available to date, to detect which patients will develop systemic envenomation, and diagnosis is based on clinical symptoms and laboratory tests. Treatment is based in a combination of detailed history, clinical examination of the affected extremity, close monitoring of cardiovascular and respiratory function. Laboratory tests that include evaluation of blood coagulation, creatine kinase, electrolytes, urea, creatinine and urine excretion are paramount in preventing and treating severe complications like coagulopathy and rhabdomyolysis that could lead to renal failure[6], [7]. Reports on child envenomation in the southern European region, are scarce in the literature. In a systematic review by Chippaux the annual incidence in Europe was 7992 cases with only 4 deaths per annum. Children and males were more affected and immunotherapy was administered in one in three cases, with high geographical variability[8]. In a large series by Karabuva et al, [9] of 160 children and adolescents, 56% were bitten in the upper limb and 7.5% developed compartment syndrome. In their series only one child died after being bitten in the neck. In another report from Claudet et al [10] that included 83 children, being bitten on the upper extremity, intense initial pain and high plasma glucose levels were associated with more severe envenomation. Small children seem to be more severely affected [11] and high vigilance for the development of compartment syndrome is required from 6–60 hours after the bitte[12]. In another large series of 219 patients, children were more susceptible to the development of compartment syndrome compared to adults[4], which should be taken into account when treating pediatric cases of viper bites.

Viper bitte in children even though it is a rare event, prompt management is very important for the successful treatment. Children seem to be more sensitive in developing compartment syndrome than adults. Early involvement of orthopedic surgeons in the assessment of the affected extremity is important for maintaining limb function and preventing serious adverse events.

Hellenic Statistical Authority	ELSTAT
Intensive Care Unit	ICU

Competing Interests

The authors have no relevant financial or non-financial interests to disclose

Ethics Approval

This study was performed in line with the principles of the Declaration of Helsinki. It received approval by the Scientific Committee of “Ippokratio” Hospital of Thessaloniki.

Consent to Participate

Written Informed consent was obtained from the parents of all participants

Consent to publish

The authors affirm that the parents of human participants provided informed consent for publication of the images in Figures. 1,2,3

Funding

This work received no funding from Public or Private sector

Author Contribution

All authors contributed to the study conception and design. Authors A.D and G.Chr. were the leading surgeons of the operations and contributed to editing the manuscript. Authors K.V., B.K. and T.Th. contributed to the data acquisition. Author C.V contributed to drafting the manuscript and data curation. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Karabuva S, Vrkić I, Brizić I, Ivić I, Lukšić B (Mar. 2016) Venomous snakebites in children in southern Croatia. Toxicon 112:8–15. 10.1016/j.toxicon.2016.01.057
Claudet I, Grouteau E, Cordier L, Franchitto N, Bréhin C (2016) Hyperglycemia is a risk factor for high-grade envenomations after European viper bites (Vipera spp.) in children. Clin Toxicol (Phila) 54(1):34–39. 10.3109/15563650.2015.1113542
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No competing interests reported.

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Orthopedic Involvement in Viper Bitte in Children in Greece. A Single Center Experience

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