Immediate Management: Urgent Fasciotomy
This child requires urgent fasciotomy for impending compartment syndrome—the combination of swelling, redness, pain, and paresthesia in the setting of a distal radius fracture represents a surgical emergency that demands immediate decompression, regardless of intact distal pulses.
Clinical Reasoning
Why Fasciotomy is Indicated
Paresthesia is the critical warning sign: The presence of paresthesia (nerve dysfunction) alongside pain, swelling, and redness indicates that compartment pressures have already compromised nerve function, which occurs before arterial occlusion 1, 2.
Intact pulse does NOT rule out compartment syndrome: Distal pulses remain palpable until very late stages of compartment syndrome because arterial pressure (typically 120 mmHg systolic) far exceeds compartment pressures needed to cause tissue damage (30-40 mmHg) 2, 3.
Children are at particular risk: Distal radius fractures in children can develop compartment syndrome, and the diagnosis is often more difficult in pediatric patients, making clinical vigilance essential 2.
Time-Critical Nature
Early decompression yields better outcomes: Studies specifically examining compartment syndrome following forearm fractures in children demonstrate that early fasciotomy produces significantly better results than delayed intervention 2.
Nerve damage progresses rapidly: Once paresthesia develops, irreversible nerve and muscle damage can occur within 6-8 hours, making this a true surgical emergency 1.
Management Algorithm
Immediate Actions (Within Minutes)
- Remove all circumferential dressings/casts immediately if present 1
- Elevate the limb to heart level only (not above, as excessive elevation may reduce perfusion) 1
- Urgent orthopedic consultation for fasciotomy 1, 2
Surgical Intervention
- Perform fasciotomy of all forearm compartments: Both volar and dorsal compartments must be released 1, 2
- Do not delay for compartment pressure measurements in the presence of clear clinical signs (paresthesia + pain + swelling) 2
- Consider fracture stabilization at the time of fasciotomy to prevent further soft tissue injury 1
Post-Fasciotomy Care
- Avoid circular casts: Use splints only to allow for continued swelling 1
- Serial neurovascular examinations to monitor recovery 2
- Plan for delayed wound closure or skin grafting once swelling resolves 1
Why Hand Elevation Alone is Inadequate
Elevation is an adjunct, not definitive treatment: While elevation may help reduce swelling in early stages, it cannot reverse established compartment syndrome once paresthesia has developed 1.
The presence of paresthesia indicates the window for conservative management has closed: This symptom signifies that tissue pressures have already exceeded the threshold for nerve ischemia 2.
Common Pitfalls to Avoid
Do not wait for loss of pulses: This is a late and ominous sign; by the time pulses disappear, irreversible damage has often occurred 2, 3.
Do not rely solely on pain assessment in children: Children may not reliably communicate pain severity, making objective findings like paresthesia even more critical 2.
Do not delay for imaging or pressure measurements: Clinical diagnosis based on the constellation of symptoms (pain, paresthesia, swelling, tense compartments) is sufficient to proceed with fasciotomy 1, 2.
Unremitting pain warrants reevaluation: Any patient with persistent or worsening pain after distal radius fracture requires immediate reassessment for compartment syndrome 4.