O1069: When Are Prophylactic Forearm Fasciotomies Needed After Pediatric Upper Extremity Revascularization Surgery?

Background: The purpose of this retrospective study was to determine the need for prophylactic forearm fasciotomies after upper extremity revascularization procedures in the pediatric population.

Methods: A retrospective chart review was performed of pediatric patients < 19 years old who underwent upper extremity revascularization at a single pediatric tertiary referral center from January 2009-May 2021. Twenty-seven patients were identified using ICD-9,10 codes and diagnosis search for upper extremity vascular injury and CPT search for upper extremity revascularization. Poor outcome was defined as persistent range of motion or neurologic deficits at final documented follow-up. Categorical variables were compared with chi-square test or Fisher’s exact test. Continuous variables were compared with T-test or Mann-Whitney, as appropriate, between normal and poor outcome groups.

Results: Mean age was 8.4years (range, 1.6-16.4), and 81% were male (22/27). 23 had revascularization surgery alone (GroupR), and 4 had revascularization surgery followed by immediate prophylactic fasciotomy (GroupFR). While both mean time from injury to revascularization was longer in GroupFR compared to GroupR (18.9v11.3hours), this was not statistically significant (p>0.05). No patients in GroupR developed subsequent compartment syndrome or required delayed fasciotomy. Most common mechanism of injury was blunt (n=12), penetrating trauma (n=11), and crush injuries (n=4). 16 patients required orthopedic intervention for a fracture (n=15) or a dislocation (n=1); 3 of these had prophylactic fasciotomies. 3 patients required blood transfusions. Only 1 patient presented with an ischemic, pulseless arm; the rest were pink, perfused, but pulseless.
Fourteen patients presented with neurologic injury; 3 who did not have prophylactic fasciotomies had continued neurologic deficits at final follow-up although 2 did not follow-up past 40 days. Mean follow-up was 250 days (range, 28-1607). All patients had palpable radial pulses at follow up. One GroupR patient developed a superficial wound drainage treated with local wound care without antibiotics while another developed a deep and delayed infection after an open grade IIIC supracondylar humerus fracture. Poor outcomes (8 with limited motion/contractures, 1 with persistent nerve sensitivity) occurred in 9 (36%) patients, 7 in group R and 2 in Group FR. There were no deaths or limb amputations.
Bivariate analyses showed that adolescents (age 10-18), elevated creatinine (0.73 vs 0.44), decreased INR (1.3 vs 2.0), and abnormal partial thromboplastin time (either low or high compared to normal range) were associated with poor outcomes (p < 0.05). Neither time from injury to revascularization nor ED to revascularization were significantly associated with poor outcomes (p>0.05).

Conclusion: In practice, prophylactic forearm fasciotomies following upper extremity revascularization are not always performed in pink, perfused, but pulseless pediatric patients. Experienced surgeons may consider close observation of the pediatric patient after upper extremity revascularization without ischemia in lieu of performing prophylactic fasciotomies.