Volkmann Contracture and Compartment Syndromes after Femur Fractures in Children Treated with 90/90 Spica Casts

Abstract

Nine pediatric patients (mean age 3.5 yrs) with low energy femur fractures were treated with 90/90 spica casts and developed leg compartment syndromes, Volkmann contracture, and ankle skin loss. These cases are detailed and a proposed mechanism leading to this devastating complication is explained. The authors believe the technique of an initial below knee cast, and then using that cast for applying traction while immobilizing the child in the 90/90 spica is potentially dangerous. Alternative spica application methods are advocated.

Full text

Volkmann Contracture and Compartment Syndromes
after Femur Fractures in Children Treated
with 90/90 Spica Casts
Scott J. Mubarak, MD,* Steve Frick, MD,ÞErnest Sink, MD,þKarl Rathjen, MD,§
and Kenneth J. Noonan, MD||
Abstract: Nine pediatric patients (mean age 3.5 yrs) with low
energy femur fractures were treated with 90/90 spica casts and
developed leg compartment syndromes, Volkmann contracture, and
ankle skin loss. These cases are detailed and a proposed mechanism
leading to this devastating complication is explained. The authors
believe the technique of an initial below knee cast, and then using
that cast for applying traction while immobilizing the child in the
90/90 spica is potentially dangerous. Alternative spica application
methods are advocated.
Key Words: spica cast, compartment syndrome, Volkmann’s,
femur fracture
(J Pediatr Orthop 2006;26:567Y572)
Compartment syndromes and Volkmann contractures in
the leg have occurred after femur fractures treated with
traction and after applying a spica cast. Bryant traction used
to treat a small child’s femur fracture was the first observed in
1955.
1
This problem can even occur on the uninvolved side,
and was found to be related to the child’s size and the leg
elevation. A later report using Buck traction on an elevated
Bradford frame to treat a child’s femur fracture was also
implicated in producing compartment syndrome of the
posterior compartments.
2
No reports of compartment syn-
dromes or Volkmann contracture after femur fractures treated
with a spica appeared in the literature until 2003.
3
This report
implicated the 90/90 position and described multiple
potential contributing factors. We are reporting 7 cases in
addition to the 2 from Large and Frick paper to educate
surgeons about this potential complication, and to clarify the
pathogenesis of this type of compartment syndrome and
resulting Volkmann contracture.
METHODS
Of the 9 patients, 6 were from 4 of the authors’ insti-
tutions (as mentioned, 2 of these were previously reported).
Three patients were from lawsuits the authors were asked to
review. In all 9 cases, the medical records, radiographs, and
clinical photographs were reviewed by the senior author. The
spica cast films and operative reports were studied in detail to
document the spica application technique and position. Seven
of the 9 patientssustained their fractures with low energy. Only
2 were struck by automobiles. Human subjects board approval
was obtained before this retrospective review.
RESULTS
The age range of these patients was 1 1/2Y5 years, with the
mean 3.5 years. Eight of the 9 patients were males and 7 of 9 had
left femur fractures. Most were spiral midshaft fractures (Fig. 1).
Two had associated injuries, including 1 with a head injury and 1
with abdominal trauma which required exploratory laparotomy
(Table 1). None of the patients had an ipsilateral injury to the tibia
or leg.
All 9 children were treated with a 90/90 spica cast, with
8 of the 9 children having first a below knee cast applied and
then the remainder of the spica cast (Fig. 2).
4
The patients began showing signs of compartment syn-
drome 2Y32 hours after spica application. Frequently these
signs were appreciated only in retrospect, and thus only 5 of the
children had their casts removed and fasciotomies performed.
Fasciotomies were performed on 5 children, from 1.5 to 8 days
postinjury. Four children had no fasciotomy.
All of the children had pressure problems, with both skin
and deep muscular necrosis of the proximal half of the pos-
terior calf (involving the superficial and deep posterior com-
partments) (Fig. 3). Seven of the 9 also had anterior ankle
pressure sores with full thickness skin loss (Fig. 4). Most re-
quired skin grafting and multiple reconstruction surgeries for
leg and foot contractures.
DISCUSSION
The pathophysiology of compartment syndromes is
well defined.
2,5,6
The relationship between pediatric femur
fractures, compartment syndromes, and Volkmann contrac-
tures was first described by Nicholson et al.
1
They reported on
Volkmann contracture in both injured and uninjured legs in
children treated with Bryant overhead traction. Subsequent
ORIGINAL ARTICLE
J Pediatr Orthop &Volume 26, Number 5, September/October 2006 567
From the *Department of Orthopaedics, Children’s Hospital and Health
Center, San Diego, California, CA; †Carolinas Medical Center Ortho-
paedics, Charlotte, NC; ‡Department of Orthopaedics, The Children’s
Hospital, Denver, CO; §Department of Orthopaedics, Texas Scottish Rite
Hospital, Dallas, TX; and ||Department of Orthopaedics and Rehabilita-
tion, University of Wisconsin, Madison, WI.
None of the authors received financial support for this study.
Reprints: Scott J. Mubarak, MD, 3030 Children’s Way, Suite 410, San Diego,
CA 92123. E-mail: pedsortho@chsd.org.
Copyright *2006 by Lippincott Williams & Wilkins
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recommendations were to avoid Bryant traction as a treatment
for femur fractures in patients older than 2 years. Mubarak and
Carroll, in a review of 55 cases of Volkmann contracture in
children, found that 21 were related to femur fractures.
2
Nearly
all of these patients were treated with a Buck traction on an
elevated Bradford frame. Most of the damage occurred in the
superficial posterior compartments of the involved leg. More
recently, Janzing presented 2 cases of compartment syndromes
in 3 patients treated with skin traction: one of these children
developed the complication in the uninjured leg.
7
All of these
authors theorized that compartment syndrome after pediatric
femur fracture treated with traction resulted from a combina-
tion of arterial spasm, increased tissue pressure from the injury,
and elevation of the leg.
There are many series advocating spica cast in children
younger than 10 years
8Y17
and more recently decreasing the
age to younger than 6 years because of the increasing pop-
ularity of flexible intramedullary nailing and other operative
treatment methods.
6,16,18
Surprisingly, the technique of spica
cast application has not been illustrated in recent textbooks. In
1984, Staheli recommended hip flexion in the cast to vary
between 20 and 45-degree angle depending on the location of
the fracture.
16
In 1984, a large series out of Little Rock by
Henderson, Morrissy, Gerdes, and McCarthy stressed early
casting for femoral shaft fractures in younger children.
10
Two
years later in 1986, Richard McCarthy published a technique
paper on early spica cast application using: (1) a cylinder cast
applied to the leg, (2) a torso component of the spica, and (3)
traction and the thigh portion.
19
This 3 part spica application
was presented as a technique without supportive cases.
This 90/90 spica with initial below knee cast has become
quite popular over the past 20 years.
13
In 1998, the Boston
Children’s Hospital Physicians
20
reported 114 cases treated in
the 90/90 position with 14% skin problems, but no other major
difficulties described. In 1999, Czertak and Hennrikus reported
23 children younger than 6 years with similar good results.
They also stated thatthe Bshort leg cast was used as a joystick to
reduce the femur fracture.^
21
This position was advocated by
the authors as a more ideal position for obtaining the reduction
and maintaining length. It was also reported to be better for
sitting, car seat use, and toileting. Reflecting on the recent
enthusiasm for 90/90 spica technique,
7
Ogden preferred
method is described in his book.
14
He recommends placing a
short leg cast first, then the pelvis and opposite leg, and
application of traction through the short leg cast, whereas the
remainder of the cast is applied to the injured leg. Even more
concerning was a paper published in late 2005 of 145 femur
fractures in children younger than 7 years, treated by this
method. Thirty-three percent were sent home. No cases of
compartment syndrome were reported, but 2 patients had
Bsignificant skin ulcerations^.
22
In 1992, Weiss, Schenck, Sponseller, and Thompson
presented 4 cases of peroneal nerve palsy using this 3 part spica
casting technique.
23
This complication had not been previously
reported. They recommended better padding of the peroneal
nerve, and applying the initial cast above the knee before
application of the thigh portion. This modification is somewhat
similar to the technique advocated by Irani et al (85 patients)
and Ferguson and Nicol et al (100 patients).
9,12
In these studies,
they used an initial above knee cast followed by the remainder
of the spica. To our knowledge, this method of initial long leg
cast has not been associated with compartment syndrome and
Volkmann contracture.
The first report of compartment syndrome in a child
treated with a spica cast was by Large and Frick in 2003.
3
They
described 2 children who developed a Volkmann contracture
after femur fracture treated with 90/90 spica. They hypothe-
sized that both elevation and increased pressure in the calf
contributed to the development of the compartment syn-
drome. They believed that the elevation of the leg in 90/90
position led to hypoperfusion, ischemia, and rebound
swelling similar to cases of hemilithotomy induced compart-
ment syndromes.
4,6,24,25
They also theorized that pressure on
the posterior calf is an additional factor in the development of
the compartment syndrome with this spica technique. They
noted a study of the hemilithotomy position in an adult model
that found any elevation of the leg reduced the ankle’s
arterial blood pressure by 50%.
25
Additionally, the calf
support of the well leg support added significantly to the
pressure in the superficial posterior and lateral compartments.
In some cases, this Bdouble hit^decreased the pressure
difference between the tissue pressure and the mean arterial
pressure to less than 10 mm Hg.
25
FIGURE 1. A, Five-year-old boy with a spiral fracture in his left
femur. B, The patient in his 90/90 spica. C, Two months
later showing the patient’s healed femur. This patient’s leg
results are illustrated in Figures 3C and 4C.
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TABLE 1. Nine Patients with Femur Fractures Treated in 90/90 Spica and Result in Compartment Syndrome/Volkmann Contracture
Case No. Sex Age Side Femur Type
Observed
in Hospital CS Signs
Signs
Appeared (h)
Castoff
(d) Fasciotomy
Ankle
Pressure
Sore Femur RX Sequelae
Reconstructive
Operations
1 Male 3.5 Left Spiral No No V14 None Yes Spica Ankle = 6 cm
calf loss = 50%
Debridements
2 Male 1.8 Left Spiral Yes No V12 None Yes Spica Contractures 2 Operations; TAL
and toe flexors
3 Male 5 Left Spiral Yes Pressure 38 Y56 2 Y48 2 Yes Yes Spica flex
nails
Dorsal ankle blistering;
varus foot
Varus foot
correction
4 Male 2.5 Left Transverse mid Yes No Head injury 30 None Yes Spica Cavovarus foot Foot correction;
Ilizarov scheduled
5 Male 3.1 Left Spiral Yes Pain in ER 24 2 Yes Yes Cast Ex Fix Large loss of
all muscle
Many debridements
skin grafting
6 Female 3 Left Oblique, prox Yes Foot swelling 32 1.5 Yes No Spica Calf loss = 50% 2 Recon operations
7 Male 4 Left Spiral Yes Pressure 48 Y60
M/S out
168 7 Yes Yes Cast Ex Fix Loss all 4 comp 2 Recon operations
8 Male 5 Right Midshaft Yes M/S out, cool foot
pulse down
18 2 Yes No Cast Ex Fix Loss all 4 comp;
no motor,
min sensation
Many debridements
AFO
9 Male 5 Right Spiral Yes Pain, poor toe
movement
6Y8 14 None Yes Cast Ex Fix Large post calf loss Many debridements
skin grafting
Mean age 3.5
Ex Fix indicates external fixator; M, motor; S, sensory; CS, compartment syndrome; RX, treatment; AFO, ankle foot orthosis; TAL, tendo achilles lengthening.
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We have reviewed the initial 2 cases and added 7 ad-
ditional patients who sustained compartment syndrome after
spica cast treatment of a femur fracture. We believe that the
pathogenic factors are traction, elevation, and pressure.
The most severe damage in these children’s legs was in
the superficial and deep posterior compartments (Fig. 3), and 7
of the 9 sustained anterior ankle pressure sores (Fig. 4). Ap-
plication of the below knee cast initially (Fig. 2A), followed by
FIGURE 3. AYC, Most severe damage to the skin and proximal posterior compartments of the leg, as illustrated in 3 different
children all younger than 5 years.
FIGURE 2. Application of the 90/90 spica and pathogenesis of the resulting problems. A, Below knee cast is applied whereas the
patient is on the spica frame. B, Next traction is applied to the below knee cast to produce distraction at the fracture site. The
remainder of the cast is applied, fixing the relative distance between the leg and the torso. C, After the child awakens from general
anesthesia, there is a shortening of the femur from muscular contraction which causes the thigh and leg to slip somewhat
back into the spica. This causes pressure to occur at the corners of cast (see arrows, ie, proximal posterior calf and anterior ankle).
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longitudinal traction in the 90/90 position although under
anesthesia, can generate pressure on the skin and underlying
muscles in these children’s legs (Fig. 2B). The position is then
fixed by applying the proximal portions of the spica in the
90/90 position (Fig. 2C). When the child awakens from
anesthesia and the muscles contract, there will be a force
tending to pull the leg back into the spica, which may account
for the pressure problems at the right angle corners of the cast.
Swelling of the leg and ankle may also push the soft tissues up
against the right angles of the cast (Fig. 2D). If the child’s leg
is kept in the elevated position there will be decreased
perfusion, and furthermore gravity may cause further slippage
of the involved limb into the spica. Pressure sores involving
the skin, and underlying tissues of the proximal calf and
anterior ankle were seen in nearly all our patients.
Although many patients across the United States have
undoubtedly been treated successfully with a 90/90 spica ap-
plied using the below leg cast, we believe this series of patients
FIGURE 4. Seven of the 9 children had severe skin pressure sores over the anterior ankle, as illustrated in Figures AYE.
FIGURE 5. Authors recommended
technique of spica cast application.
A, The patient is placed on a child’s
fracture spica table. The leg is held
in about 45-degree angle of flexion
at the hip and knee with traction
applied to the proximal calf. B, The
1 1/2 spica is then applied down to
the proximal calf. Molding of the
thigh is accomplished during this
phase. C, The x-rays of the femur
are obtained and any wedging of
the cast that is necessary can occur
at this point in time. D, The leg
portion of the cast and the cross bar
are applied. The belly portion of the
spica is trimmed to the umbilicus.
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demonstrates that this technique has the potential to increase
the pressure in the posterior compartment of the leg which may
contribute to devastating neurovascular complications.
The authors recommend caution when using any cast as a
skin traction device to reduce a fracture. Safer techniques of spica
application have been used in the past,
15,16,20
and the senior
author’s technique (used for 30 yrs) is illustrated (Figs. 5A YE).
Important features include traction to the fractured leg applied by
the surgeons hands and not through cast. Also the hip and knee
flexions in the spica are around 45-degree angle each. We also
recommend admitting all patients for cast care instruction and
neurovascular checks.
Most of the children reported here developed compart-
ment syndrome after having low energy femur fractures that
could have been managed with minimal immobilization, with
fractures healing in 4 weeks without problems. Regardless of
the spica casting technique, this report again demonstrates the
potential for compartment syndrome to develop and the need
for vigilance in assessing children with femur fractures. The
patients in this report all had delayed or missed diagnosis of
their compartment syndromes.
In summary, we believe the technique of an initial
below knee cast, and then using that cast for applying traction
while immobilizing the child in the 90/90 spica is dangerous.
We advocate for alternative casting or treatment methods.
ACKNOWLEDGMENTS
This study is conducted at Children’s Hospital and
Health Center, San Diego, California.
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Mubarak et al J Pediatr Orthop &Volume 26, Number 5, September/October 2006
572 *2006 Lippincott Williams & Wilkins
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