Forearm compartment syndrome in the newborn: report of 24 cases

Neonatal Limb Compartment Syndrome: A Comprehensive Review

PURPOSE

Neonatal limb compartment syndrome (NLCS) is a rare and potentially limb-threatening condition defined as an increased pressure within a confined limb compartment. Clinicians may fail to distinguish NLCS from other mimicking conditions. Misdiagnosis is possible due to a low index of suspicion for this condition, which may delay appropriate and urgent treatment. A comprehensive review of the available literature was performed to explore common themes in NLCS and identify gaps in the evidence to guide future studies.

METHODS

A literature search was conducted in PubMed, Scopus, and Google Scholar electronic databases to identify original articles and reviews in English or French. Studies were selected by two independent reviewers who extracted descriptive data including the delivery history and complications, the timing of diagnosis, the location of the lesion, and the management strategy.

RESULTS

A total of 43 reports describing 86 cases of neonatal compartment syndrome were published between 1980 and 2021. The male-to-female ratio was 6:7. Compartment syndrome was mainly located in the upper extremity (95.3%). Clinical features including swelling (41%), sentinel skin lesion (94.2%), extremity cyanosis (89.5%), and necrotic fingers (7%) were observed. The treatment strategy was either surgical decompression (32.6%) or nonsurgical management (68.6%). Sequelae occurred at a rate of 16.6%, 81.3%, and 75.9% after early fasciotomy (< 24 hours), late fasciotomy, and nonsurgical management, respectively.

CONCLUSIONS

Sentinel skin lesions and flaccid paralysis are the most observed clinical features and represent key clues for diagnosis. Neither radiography, Doppler ultrasound, nor magnetic resonance imaging has demonstrated any advantage in guiding the appropriate management of NLCS and may delay appropriate treatment. Despite nonsurgical management and late fasciotomy (> 24 hours) being the most described treatments, the lowest rate of sequelae was observed when decompression was performed within the first 24 hours.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Delayed onset of neonatal compartment syndrome associated with compound fetal presentation

Neonatal compartment syndrome, although rare, has a classic presentation with sentinel skin findings and development of swelling, erythema, and tenderness of the affected extremity. Neonatal compartment syndrome requires prompt surgical intervention to preserve the affected limb and ensure its normal growth and development. Our patient was born at term via vaginal delivery complicated by a compound presentation involving the left upper extremity. No physical exam abnormalities were noted at birth, but she developed signs of neonatal compartment syndrome by 15 h of life. She was surgically treated at 22 h of life and recovered well. At one year of age, she has normal growth and function of the affected extremity. Our case adds to the growing literature associating neonatal compartment syndrome with a compound fetal presentation.

Practical Review on the Contemporary Diagnosis and Management of Compartment Syndrome

Acute compartment syndrome (ACS) is a limb-threatening pathology that necessitates early detection and management. The diagnosis of ACS is often made by physical examination alone; however, supplemental methods such as compartment pressure measurement, infrared spectroscopy, and ultrasound can provide additional information that support decision-making. This practical review aims to incorporate and summarize recent studies to provide evidence-based approaches to compartment syndrome for both resource-rich and -poor settings among several patient populations.

Congenital brachial artery occlusion causing neonatal forearm compartment syndrome

Congenital brachial artery occlusion is rare. We report four patients who presented at birth with absent wrist pulses. We propose management recommendations that include anti-coagulation, duplex ultrasound assessment and fasciotomy surgery as early as is safe and possible.

Neonatal Vascular Access Practice and Complications: An Observational Study of 1,375 Catheter Days

Vascular access devices play vital roles within neonatal care. We aimed to identify neonatal vascular access device insertion and management practices, and describe the incidence and risk factors for complication development. This is a prospective cohort study of neonates requiring vascular access devices over 3 months in an Australian quaternary-referral neonatal intensive care unit. In addition to describing current practices, primary outcomes were device failure, complications, and skin complications. Results are reported using descriptive statistics and with risk factors calculated via Cox proportional hazards regression. A total of 104 neonates required 302 vascular access devices, over 1375 catheter days. Peripheral intravenous catheters (PIVCs) were most used (n = 186; 62%), followed by umbilical venous catheters (n = 52; 17%). Insertion attempts were often undocumented; but for those recorded, 5% of devices (n = 15) required 4 attempts or more. Device failure occurred in 28% (n = 82), at an incidence rate of 62.5 per 1000 catheter days (95% confidence interval [CI] 49.7-75.9). Failure was most frequent in PIVCs (37%; n = 68), peripheral arterial catheters (33%; n = 2), and peripherally inserted central catheters (20%; n = 6). Infiltration and extravasation were the most frequent cause of PIVC failure (12%; n = 35). A birth weight less than 1500 g was associated with a significant decrease in PIVC failure (hazard ratio 0.58; 95% CI 0.34-0.99).

An unexpected case of neonatal compartment syndrome associated with congenital anomalies of kidney and urinary tract

Objectives

Neonatal compartment syndrome (NCS) occurs when increased pressure within the fasciocutaneous compartment decreases capillary perfusion, causing irreversible tissue damage from ischemia. NCS is a rare condition that requires prompt diagnosis and treatment. Diagnosing NCS is highly dependent on the examination, which can be difficult in newborns. Prompt recognition provides the best chance for good outcomes.

Case presentation

We present a case of NCS diagnosed and treated based on physical examination findings. Fetal ultrasonography showed bladder distension, bilateral hydroceles, urethra dilation, and abdominal urinary ascites concerning for lower urinary tract obstruction and possible bladder rupture. At 1 h after birth, examination of the infant's left upper extremity showed no spontaneous movement, the hand and forearm appeared dusky, and the hand had a large blister with desquamation. No pulse distal to the antecubital fossa was detected via Doppler ultrasonography. The infant was diagnosed with NCS and underwent urgent fasciotomy. The clinical appearance and perfusion of the left upper extremity gradually improved. At four months of age, the wounds were healed and the patient had full passive range of motion of the left upper extremity. Recovery of active motion is ongoing.

Conclusions

The presence of blistering and desquamation should provoke suspicion for NCS. Once NCS is diagnosed, prompt intervention is necessary to reduce the risk of poor functional outcomes. This case highlights the need for increased awareness of the risk developing compartment syndrome in utero as part of the rare sequalae in infants with congenital anomalies of kidney and urinary tract.

Review article: A comprehensive review of unusual causes of acute limb compartment syndrome

Acute limb compartment syndrome (ALCS) is a surgical emergency that can have serious consequences unless promptly diagnosed and treated, which is particularly challenging when there is an unusual cause. This is a comprehensive review of reported causes of ALCS. From 1068 included articles, we found 299 discrete causes of ALCS including toxins, infections, endocrine pathology, haematological emergencies, malignancy and iatrogenic ALCS. Familiarity with this wide range of ALCS causes may assist in early diagnosis of this limb-threatening condition.

Microsurgical Salvage of Neonatal Upper Limb Ischaemia Following Intrauterine Brachial Vessel Constriction

Neonatal limb ischaemia is a rare disease entity with devastating morbidity, including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. 

We report a case of limb revascularisation and salvage due to intrauterine brachial artery thrombosis. Published literature is limited to case reports and case series, with various treatment modalities discussed. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of life-long morbidity.

A male baby at (36+6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularization was achieved with a contralateral interposition reversed great saphenous vein graft. 

Though extremely rare and the clinical presentation varies with the location and timing after birth, the surgeon should maintain a low threshold for suspicion of in the presence of the characteristic sequelae of ischaemia. Doppler ultrasonography can aid the diagnosis where ambiguous, and therapy should be individualised based on the clinical presentation; this case emphasises the role of surgery in limb salvage.

Congenital Contracture of the Ulnar Digits and Its Differentiation From Ischemic Contracture

PURPOSE

To describe the clinical features, radiologic findings, differential diagnosis, and surgical treatment of a congenital flexion deformity of the middle, ring, and little fingers. The cause of the condition is the aberrant origin of the flexor digitorum profundus, leading to a congenital contracture of the ulnar digits.

METHODS

We reviewed 8 patients with congenital contracture of the ulnar digits. The mean age at the time of surgery was 14 years. An examination revealed a flexion contracture of the middle, ring, and small fingers. Plain radiographs, 3-dimensional computed tomography, magnetic resonance imaging, and ultrasound were used to characterize bony and soft tissue pathology. Surgical treatments included resection of the aberrant origin and a muscle-sliding procedure.

RESULTS

Bony prominence on the proximal ulna was seen in the plain radiographs and/or 3-dimensional computed tomography. A cord that extended from this bony prominence to the tendons of flexor digitorum profundus was revealed in the magnetic resonance imaging. The bony prominence and the cord were also seen using ultrasound. The median time of patient follow-up was 1.7 years. A simple resection of the tendinous origin only resulted in a release in 2 patients who were 4 years old. Older patients required a further muscle-sliding procedure. The average grip strength ratio on the contralateral side was 82%.

CONCLUSIONS

Congenital contracture of the ulnar digits is a new congenital flexion deformity involving the middle, ring, and small fingers. Bony prominence on the proximal ulna is the key finding for establishing its diagnosis and distinguishing it from an ischemic contracture. We recommend treating this surgically at 12 years of age or older after the phase of rapid growth of the extremities. We recommend the resection of the aberrant origin, combined with a muscle-sliding procedure, as the treatment of choice, even for young patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic V.

Free latissimus dorsi flap for upper extremity reconstruction in a 9-month-old

Successful outcomes for free tissue transfer are well-documented in pediatric patients but less so in infants. Challenges with infants are unique and include implications of prolonged anesthetic exposure. We present a 9-month-old female who underwent a free latissimus dorsi flap to reconstruct a congenital upper extremity lesion threatening limb development.

Neonatal Forearm Compartment Syndrome Secondary to Intrauterine Brachiocephalic Arterial Thrombosis: A Case Report

CASE

A newborn presented with necrotic skin lesions and contractures of the right upper extremity. Ultrasonography indicated the presence of a brachiocephalic artery thrombosis, and clinical examination demonstrated a neonatal forearm compartment syndrome. Surgical treatment included decompressive fasciotomy of the right forearm. The right-sided brachiocephalic thrombosis resulted in left hemiplegic cerebral palsy. At the 3-year follow-up, the patient had near-normal function of the right upper extremity. This case has detailed preoperative video and follow-up to illustrate this rare but modifiable condition.

CONCLUSION

This case demonstrates a unique cause of neonatal forearm compartment syndrome (brachiocephalic arterial thrombosis) and the results of prompt surgical treatment.

Stimulated biofeedback training for a child with Becker muscular dystrophy and compartment syndrome in the left forearm

Background: Muscular dystrophy negatively affects ambulation, mobility, self-care, and community involvement. Neonatal compartment syndrome (NCS) causes loss of muscle strength, sensory problems, and limb dysfunction. Patients with Becker Muscular Dystrophy (BMD) and/or NCS may benefit from individualized rehabilitation to improve function.Purpose: This case report describes stimulated biofeedback training (SBT) to improve the functional level, muscle strength, balance, and hand function in a child with BMD and NCS.Case Description: An 8-year-old male patient with BMD and NCS in the left forearm received 12-weeks of SBT. The functional level was assessed by the Motor Function Measurement-32 (MFM-32), muscle strength by a hand-held dynamometer, balance by the Neurocom Balance Master, and upper limb function by the Quality of Upper Extremity Skills Test (QUEST) at the initial examination, after 6 weeks and after 12 weeks of treatment. Laboratory tests to monitor changes in serum creatine kinase were performed throughout the episode of care.Outcomes: The laboratory values remained within the appropriate range to continue SBT. Functional level, hand function, hip, and knee flexion/extension strength, and dorsiflexion strength improved.Conclusions: This case report suggests that SBT safely and effectively improved functional level, muscle strength, and hand function in this child with BMD and NCS.

Neonate born with ischemic limb to a COVID-19 positive mother: management and review of literature

Objectives

To describe challenges in diagnosis and treatment of congenital neonatal gangrene lesions associated with history of maternal coronavirus disease 2019 (COVID-19) infection.

Case presentation

A preterm neonate was born with upper extremity necrotic lesions and a history of active maternal COVID-19 infection. The etiology of his injury was challenging to deduce, despite extensive hypercoagulability work-up and biopsy of the lesion. Management, including partial forearm salvage and hand amputation is described.

Conclusions

Neonatal gangrene has various etiologies, including compartment syndrome and intrauterine thromboembolic phenomena. Maternal COVID-19 can cause intrauterine thrombotic events and need to be considered in a differential diagnosis.

Complete Decompression of a Forearm Neonatal Compartment Syndrome Using a Volar Approach: A Surgical Technique

Fasciotomy of the forearm is a well-described technique for the treatment of compartment syndrome in adults; however, it has not been discussed with sufficient details in the setting of neonatal compartment syndrome. When performing a fasciotomy, it is imperative to decompress all compartments within the forearm to limit the ischemic damage and prevent the progression of the disease. Although it is common to utilize both volar and dorsal incisions to release these compartments, we describe a method that potentially allows for total decompression through a single volar incision with minimal to no morbidity. This novel technique provides sufficient soft-tissue exposure while improving upon the cosmesis that results from a traditional approach.

Neonatal Extremity Compartment Syndrome: A Rare Diagnosis Requiring Prompt Recognition

Neonatal extremity compartment syndrome is an extremely rare diagnosis. Risk factors that predispose infants to a hypercoagulable state or trauma have been implicated, but the exact mechanisms remain poorly understood. The hallmark of the condition is extremity swelling with sentinel skin changes. We report a case of upper extremity compartment syndrome from initial presentation until 3 months after discharge and discuss the importance of prompt diagnosis and timely surgical evaluation.

Neonatal Compartment Syndrome and Compound Presentation at Birth

Neonatal compartment syndrome is a rare condition. Early diagnosis and timely surgical intervention are paramount to optimize outcome. Time to fasciotomy is the most important prognostic factor. The purposes of this study were to describe a case presentation of neonatal compartment syndrome associated with a compound birth presentation and to perform a literature review. In this case, the neonate’s fingers were noted to be present on maternal cervical examination 24 hours before delivery. The patient then was noted to have a sentinel skin lesion. A diagnosis of neonatal compartment syndrome was suspected, and she underwent urgent fasciotomy. Literature review identified a total of 60 patients from 26 studies. Most patients were managed operatively. All patients presented with a sentinel skin lesion, emphasizing the importance of this clinical sign in diagnosis. Manometry is not routinely performed and no standards are available for acceptable pressure gradients.

Neonatal Compartment Syndrome as a Result of Thromboembolic Event

Neonatal compartment syndrome is a rare condition characterized by progressive limb ischemia and tissue necrosis manifesting at birth or in the immediate postpartum period. Early recognition of clinical features and immediate surgical intervention offer the best prognosis, but unfamiliarity with this uncommon entity often results in delayed diagnosis and catastrophic consequences, including limb amputation. We present a case in a preterm neonate who developed a proximal arterial thrombus after sustaining limb ischemia in utero. This case demonstrated that even delayed treatment with appropriate therapy can result in salvage of the limb. Clinicians should be aware of the characteristic skin findings and institute appropriate measures to determine the presence or absence of compartment syndrome.

Neonatal Compartment Syndrome Treated Within the First 24 Hours of Life

Neonatal compartment syndrome is rare. There are multiple proposed etiologies, including infection, vascular insult, and mechanical compression. Much like compartment syndrome in adults, delayed surgical intervention for neonatal compartment syndrome can have catastrophic results. The authors present a unique case of a neonate who presented with left forearm and hand swelling and skin ulceration after vaginal delivery. Findings from the evaluation for vascular injury, infection, and hypercoagulability were normal. The neonate was diagnosed with compartment syndrome and underwent decompressive fasciotomy of the forearm flexor and extensor compartments as well as hand intrinsic and thenar compartments within the first 24 hours of life. At 5 years old, the patient had progressive radial clubbing and a 41-mm limb length discrepancy due to growth arrest at the distal radial physis. A radial distraction osteogenesis was then performed. Postoperatively, the patient continues to improve her range of motion and strength through rehabilitation. [Orthopedics. 2018; 41(5):e731-e733.].

Physeal bar equivalent

Premature partial physeal arrest without the formation of an osseous bar - physeal bar equivalent (PBE) - is uncommon. Four children with a PBE had an infection near the distal femoral physis before the age of 11 months. Some growth was achieved after resection of the PBE in each case. Of two cases diagnosed and treated early, one required only contralateral physeal arrests to achieve limb-length equality at maturity. The other, currently 8 years and 4 months old, has a 1.1-cm limb-length discrepancy 6 years after PBE resection and will require observation until maturity. Of two cases diagnosed and treated late, one required ipsilateral femoral lengthening and contralateral femoral shortening and physeal arrests to treat the limb-length discrepancy and angular deformity. The other, currently 7 years and 1 month old, has a 4.8-cm discrepancy and will need future surgical limb-length equalization. Early recognition and treatment of PBE is required to avoid severe limb-length inequality and angular deformity.

Pediatric Acute Compartment Syndrome

Pediatric acute compartment syndrome (PACS) is a clinical entity that must be carefully differentiated from the adult version (ie, acute compartment syndrome). Healthcare providers must understand the variable etiologies of PACS, of which trauma is the most common but can also include vascular insult, infection, surgical positioning, neonatal phenomena, overexertion, and snake and insect bites. In addition to the unique etiologies of PACS, providers must also recognize the different signs and symptoms of PACS. The three As (ie, anxiety, agitation, analgesic requirement) of PACS have supplanted the classic adult signs as being more accurate and allowing earlier detection. In children with questionable clinical signs but concern for PACS, compartment pressure measurement may be necessary to confirm the diagnosis. Overall, outcomes after fasciotomy in children tend to be excellent; however, diagnostic delays secondary to unfamiliar clinical scenarios can lead to myonecrosis and subsequent poor outcomes.

Pediatric Nonfracture Acute Compartment Syndrome: A Review of 39 Cases

BACKGROUND

Compartment syndrome in the absence of fracture is rare and poorly described within the pediatric literature. The purpose of this study was to report the varying etiologies, risk factors, and treatment outcomes associated with pediatric nonfracture acute compartment syndrome (NFACS).

METHODS

We conducted a retrospective chart review on 37 children who suffered a NFACS and were treated at a single pediatric trauma center between 1997 and 2013. Demographic, diagnostic, treatment, and outcome characteristics were reviewed. Five causal groups were generated: trauma, exercise related (acute presentation after exercise without trauma), infectious, vascular, and postoperative (in the absence of osteotomy). Univariate and multivariate analyses were performed to identify risk factors of NFACS. P-values <0.05 were considered statistically significant.

RESULTS

There were 39 cases of NFRCS in 37 children [6 females, 31 males, mean age of 11.7 y (SD+7.2 y)]. The leg was the most commonly involved limb (29 cases, 74%). Diagnosis of NFRCS was made either by compartment pressure monitoring [59%, 23/39 cases, mean pressure 66 mm Hg (SD+28)] or by clinical examination. According to etiology, vascular was most common (11/39, 28%), followed by trauma (10/39, 26%) and postoperative (8/39, 21%), with exertion and infection representing a small proportion (6/39, 15% and 4/39, 10%, respectively). Pain was present in 33 cases (85%), swelling in 28 cases (72%), paresthesias in 13 cases (33%), motor deficit in 12 cases (31%), and poor perfusion in 11 cases (28%). Average time from symptom onset to diagnosis was 48 hours (IQR, 9 to 96 h). At surgery, 21 patients (54%) had evidence of myonecrosis. Children required an average of 3 surgeries for wound closure. The median time to follow-up was 232 days (IQR, 73 to 608 d). A total of 54% made a full recovery, whereas 31% suffered a persistent neurological or functional deficit.

CONCLUSIONS

NFACS in children is associated with a delay in diagnosis and a high rate of myonecrosis. Timely assessment with high clinical suspicion is necessary to prevent a delay in diagnosis.

LEVEL OF EVIDENCE

Level IV.

Compartment Syndrome in Children

Compartment syndrome in children can present differently than adults. Increased analgesic need should be considered the first sign of evolving compartment syndrome in children. Children with supracondylar humerus fractures, floating elbow injuries, operatively treated forearm fractures, and tibia fractures are at high risk for developing compartment syndrome. Elbow flexion beyond 90° in supracondylar humerus fractures and closed treatment of forearm fractures in floating elbow injuries are associated with increased risk of compartment syndrome. Prompt diagnosis and treatment with fasciotomy in children result in excellent long-term outcomes.

Neonatal compartment syndrome

A term neonate was born with a grossly swollen and discoloured left hand and forearm. He was transferred from the local hospital to the plastic surgical unit, where a diagnosis of compartment syndrome was made and he underwent emergency forearm fasciotomies at six hours of age. Following serial debridements of necrotic tissue, he underwent split-thickness skin grafting of the resultant defects of his forearm, hand and digits. At the clinic follow-up appointment two months after the procedure, he was found to have developed severe flexion contractures despite regular outpatient hand therapy and splintage. He has had further reconstruction with contracture release, use of artificial dermal matrix, and K-wire fixation of the thumb and wrist. Despite this, the long term outcome is likely to be an arm with poor function. The key learning point from this case is that despite prompt transfer, diagnosis and appropriate surgical management, the outcome for neonatal compartment syndrome may still be poor.

Resistance to venous flow: A mathematical description and implications for compartment syndromes

BACKGROUND

The object of this work was to describe resistance to flow within a vein in a closed compartment.

METHODS

A vein is mathematically modeled as a collapsible cylinder with fixed perimeter exposed to extraluminal hydrostatic pressure within a closed compartment of the body. The principle of minimization of energy is used to determine the cross-sectional area and resistance to flow through such a cylinder in various states of collapse.

RESULTS

A mathematical expression for the cross-sectional area of a partially collapsed tube is derived. Resistance to flow is calculated within the tube in various states of collapse and compared with the resistance to flow in an annular tube of identical cross-sectional area. Resistance increases very rapidly in the first 5% of collapse and remains greater than that in an annular vessel of identical cross-sectional area through all further collapse. Resistance to flow closely follows a logarithmic gain as the tube undergoes collapse from extraluminal pressure until opposite sides of the vein make contact.

CONCLUSION

Within a closed compartment in which there is rising pressure, resistance to flow through a vein is predicted to increase as a logarithmic function of the vein's cross-sectional area. This rapid rise in resistance and hence decline in flow are consistent with the position that in compartment syndromes of all anatomic locations, the venous contribution to resistance of flow is of paramount importance to the pathophysiology.

Acute forearm compartment syndrome in a newborn caused by reperfusion after spontaneous axillary artery thrombosis

Acute compartment syndrome of the forearm in newborns is often misdiagnosed and can be disastrous if left untreated. Here, we report a full-term infant of a diabetic mother with underlying heterozygosity for MTHFR C677T and A1298C alleles. A spontaneous thrombosis occurred in the left axillary artery immediately after birth. The patient responded well to anticoagulant (heparin) and thrombolytic (tissue plasminogen activator) agents. After reperfusion of the extremity, acute compartment syndrome developed. Emergent fasciotomy was performed. In this case, effective collaboration between pediatricians and orthopedic surgeons resulted in salvage of the extremity, with good clinical and functional results.

Free myocutaneous flap transfer to treat congenital Volkmann's contracture of the forearm

The purpose of this study is to report our experience with free functional muscle transfer procedures for the late sequelae of the rare condition of congenital Volkmann's ischaemic contracture of the forearm. Four children, with an average age of 9.5 years (range 1.5-17), were treated and were followed for a mean of 6 years (range 1-14). Two patients had dorsal forearm contractures, and two had both flexor and extensor forearm contractures. We carried out free functional muscle transfers to replace the flexor or extensor muscles. The functional result was assessed according to the classification system of Hovius and Ultee. All patients had wrist contractures and skeletal involvement with limb length discrepancy that influenced the outcome. All five transferred muscles survived and improved the function of the hand in three of the four patients. LEVEL OF EVIDENCE 4.

Neonatal volkmann ischemic contracture: case report and review of literature

Background Neonatal Volkmann ischemic contracture in newborns is a devastating condition with lifelong consequences. Case Report We report a neonate born with necrotic skin lesions and bullae on right dorsal thenar aspect of hand, who subsequently developed compartment syndrome requiring fasciotomy. Review and Conclusion Necrotic skin lesions with/without swelling, bullae are invariably present at birth in these patients and should be recognized as a sentinel finding of underlying tissue ischemia/compartment syndrome. Early recognition and prompt surgical intervention can be limb saving. A range of radiologic abnormalities and contractures were noted in upto 84% of such patients followed long term. Hence, we recommend close follow-up until occurrence of epiphyseal fusion in these patients.

Severe neonatal complication of transverse lie after preterm premature rupture of membranes

Both transverse lie and preterm premature rupture of membranes (PPROM) are associated with neonatal morbidity and mortality. We present a neonate born at 29 weeks gestation with severe birth trauma after PPROM and transverse lie. The patient had extensive swelling and areas of desquamated and necrotic skin of the right lower limb. Neonatal compartment syndrome (NCS) was suspected. Perfusion of the limb improved after decompressing subcutaneous incisions. A fetus in transverse lie may be mechanically damaged in the case of PPROM, especially at an early gestational age. Early recognition is of great interest in the management and prognosis of NCS.

Forearm compartment syndrome of a newborn associated with extravasation of contrast agent

Extravasation of contrast agents is a possible complication of imaging studies. Although extravasations typically cause minimal swelling or erythema, they can lead to compartment syndrome when the volume of extravasation is high. In this article, we will present an exceptional case where an insignificant amount of contrast agent extravasation led to a forearm compartment syndrome in a newborn, who was treated with an extended fasciotomy. We would like to emphasize the preventive techniques and treatment options of this iatrogenic complication in newborns. Close followup of the patient by the nurses, awareness of the parents and the personnel in the radiology department are the most important preventive measures in this extremity-threatening complication. Forearm compartment syndrome due to contrast agent extravasation may progress more rapidly in newborns even with smaller amounts of extravasation and prompt recognition of the pathology and immediate intervention are unevitable.

Successful early surgical treatment in neonatal compartment syndrome: case report

Neonatal compartment syndrome is rare, and the diagnosis is often missed or delayed because other ischemic diseases can mimic clinical signs observed on the skin. A premature newborn infant presented with skin lesions during the first hours of life that were recognized as the sentinel finding in compartment syndrome of the newborn. We restored normal function by emergency surgery. The authors highlight the importance of effective collaboration between pediatricians and surgeons to improve the management of this neonatal condition.

Necrotizing upper limb fasciitis in a newborn: an uncommon life-threatening event

Necrotizing fasciitis is an uncommon but life-threatening infection in the pediatric population. It is rarely reported in neonates. In these rare cases, the reported origin of infection was the umbilical cord stump, infection due to circumcision, and similar lesions. We hereby report a 3-week-old neonate sustaining necrotizing fasciitis without detectable origin of infection. We describe the clinical course of her illness, the diagnostic process, and eventual surgical intervention. We discuss the importance of awareness to this potentially lethal infectious disease and the need for urgent use of certain imaging modalities and aggressive surgical approach.

Forearm compartment syndrome owing to being stuck in the birth canal: a case report

Neonatal compartment syndrome is a rare condition mainly involving the upper extremity associated with necrotic lesions. It is often initially misdiagnosed because the skin lesions mimic several other conditions of the newborn. Early diagnosis and timely intervention are of paramount importance to achieve the best outcome. In the present case, we describe a newborn with forearm compartment syndrome owing to being stuck in the birth canal.

Intrauterine extremity gangrene and cerebral infarction at term: a case report

Intrauterine extremity gangrene in combination with cerebral infarction is a serious and rare event. We present a case with a healthy mother who gave birth to a child with this condition. At term, the mother presented at the antenatal clinic with decreased fetal movements. Cardiotocography (CTG) showed signs of fetal distress and a caesarean section was performed. The left arm of the newborn was found gangrenous. Amputation of the arm was necessary and the child was subsequently treated with anticoagulant therapy due to thrombosis and cerebral infarction in the left hemisphere found by magnetic resonance imaging (MRI). At one year of age the boy was doing well and had prosthesis as a left arm. He had no signs of further complications. Despite thorough examination of the parents and the child, the reason for the thrombosis is still unknown.

Volkmann ischemic contracture in a newborn

Congenital Volkmann ischemic contracture is a very rare condition in which a neonate presents skin, muscular and nerve lesions due to increased intracompartment pressure and subsequent ischemia, probably due to extrinsic intrauterine compression. In this age group, there are only about 50 reported cases and a specific cause is unknown. The authors describe the case of a newborn who presented with bullous and ulcerated skin lesions and nerve palsy of his forearm at birth, evolving to subcutaneous and muscular necrosis and contracture. Two surgeries were performed and the baby began a daily physiotherapy program that resulted in aesthetical improvement and recovery of his hand and forearm mobility. Early recognition of this rare entity and subsequent emergency fasciotomy are the best ways to improve prognosis.

Acute compartment syndrome of the upper extremity

Acute compartment syndrome occurs when pressure within a fibro-osseous space increases to a level that results in a decreased perfusion gradient across tissue capillary beds. Compartment syndromes of the hand, forearm, and upper arm can result in tissue necrosis, which can lead to devastating loss of function. The etiology of acute compartment syndrome in the upper extremity is diverse, and a high index of suspicion must be maintained. Pain out of proportion to injury is the most reliable early symptom of impending compartment syndrome. Diagnosis is particularly difficult in obtunded patients and in young children. Early recognition and expeditious surgical treatment are essential to obtain a good clinical outcome and prevent permanent disability.