Question

You are caring for a child with an arm fracture that has recently been casted. Upon routine assessment you notice that his fingers are swollen, capillary refill is sluggish, and he is stating that his arm feels "funny". What should your first action be?

Answer 1

The early identification and management of acute compartment syndrome ( ACS: Increase in pressure of a closed muscle compartment that causes muscle and nerve ischemia) is relevant and is associated with a decreased incidence of complications and better prognosis. Acute compartment syndrome in children is a true orthopedic emergency.

Nursing management include:

• The first action of the nurse should be an Immediate assessment of neurovascular status by monitoring the 5 P's: pain, pallor, pulse, paresthesia, and paralysis.

Pallor:

The best indicator of perfusion adequacy of the extremity is being perfused, distal to the cast or injury.

Check the skin of the hand or foot for warm, pink skin, and free of swelling.

A dusky or ashy appearance shows the onset of compartment syndrome.

Check for capillary refill: note for sluggish or absent.

Pain:

Pain is the most distinguish sign. The pain will be diffuse and progressive.

Pulse:

Pulses in the extremity indicate the arterial bed is intact. Check distal pulses.

If not possible go for a sonographic assessment.

Paralysis:

The inability of dorsiflexion and plantar flexion of toes should be noted, as well as any weakness experienced.

Paresthesia:

Check for the sensation of extremities. If an abnormality occurs, should be noted and reported.

• Then do the detailed neurological assessment.
• Assess the 3A s—in children (Agitation, Anxiety, Analgesic requirement )
• Arrange for immediate medical evaluation
• Proper positioning of the extremity: to promotes venous drainage and decreases edema
• Note appearance and spread of hematoma.
• Apply ice bags around fracture site for short periods of time intermittently 24–72 hrs to reduce edema.
• If the condition is deteriorating cut plaster cast and relieve pressure
• The range of motion exercise to prevent compartment syndrome
• Use analgesics to manage pain
• Apply cast with stretch relaxation method