Acute compartment syndrome in children; beware of “silent” compartment syndrome

Rationale: Acute compartment syndrome (ACS) is a feared complication following traumatic injuries. We describe the occurrence of silent ACS of the hand in a 2-year old patient with atypical symptoms. Patient concerns: Our patient experienced massive swelling but minimal pain of the hand after a heavy bistro table with a stone tabletop had fallen on the right hand. Diagnosis: After monitoring the development of ACS for 1 night, we noted increased firmness of the swelling and impaired perfusion of the skin covering the palm and dorsum of the hand. Notably, the patient held the hand in an intrinsic minus position but did not complain of pain after administration of only a single (weight-matched) dose of ibuprofen. Our suspicion of ACS was confirmed intraoperatively because of the elevated intramuscular pressure (up to 60 mm Hg) in several hand compartments. Interventions: We performed surgical fasciotomy of all hand compartments, followed by temporary coverage of the wounds with Epigard synthetic skin substitute. The wounds were closed stepwise after 2 and 7 days, and occupational therapy was initiated after 3 weeks. Outcomes: At the 1-year follow-up, we noted unrestricted wrist and finger functions of the patient. The parents reported that there was no difference in the use of the 2 hands during daily activities. Lessons: The possible development of ACS should be borne in mind even in the absence of marked pain. Although the 3 A's (i.e., anxiety, agitation, and increased analgesic requirements) in the diagnosis of ACS in children are well established, some patients may experience only minimal pain. This challenges the correct and timely diagnosis of ACS in children, particularly if they are very young.