summary Neonatal Forearm Compartment Syndrome is a devastating upper extremity condition in neonates where the osseofascial compartment pressure rises to a level that decreases perfusion to the forearm and may lead to irreversible muscle and neurovascular damage. Diagnosis is different from compartment syndrome in adults with the primary finding in neonates being skin lesions such as bullae, eschars, ulcers, with the presence of digital and hand ischemia/edema. Treatment is usually emergent fasciotomies. Epidemiology Incidence rare limited to case reports, largest series is 24 cases over 20 years Demographics age bracket neonates during first 24 hours of life Anatomic location forearm, wrist, hand (equal R:L distribution) unilateral dorsum more common than volar Risk factors hypercoagulable states polycythemia prematurity oligohydramnios maternal diabetes multiple gestation abnormal lie neonatal respiratory distress Etiology Pathophysiology mechanism of injury possible birth trauma (see below) idiopathic is most common pathophysiology exact mechanism unknown, although both extrinsic and intrinsic factors are believed to be involved extrinsic (mechanical compression with forearm being trapped between structures) login to view 5 more bullets intrinsic (clotting) login to view 1 more bullet Presentation History idiopathic (no obvious cause) is most common cause Symptoms common symptoms all patients present with skin lesion (wide spectrum) login to view 6 more bullets duration login to view 1 more bullet Physical exam inspection skin lesion bullous swelling, erythema nerve involvement (radial nerve and PIN > ulnar = median) may have lack of spontaneous limb movement Imaging Radiographs recommended views AP and lateral forearm radiographs findings skeletal changes happen late (more evident when the child grows) login to view 2 more bullets MRI indications late-presenting cases without edema, but with extensive full-thickness necrosis and extreme contractures (where fasciotomy is likely to be futile) may help delineate full extent of underlying necrosis and guide muscle debridement Studies Labs indications to rule out infection, cellulitis findings CBC, ESR, CRP within normal values Compartment pressure indications is NOT done in neonates because login to view 2 more bullets Differential Cellulitis distinguishing features mother does not show signs of infection, has negative cultures Necrotizing fasciitis most easily mistaken for compartment syndrome, and only diagnosed/confirmed at operation distinguishing features only involves skin, subcutaneous tissue treated with excision, not fasciotomy Vascular injuries associated with brachial plexus lesions distinguishing features absent pulses and Doppler studies Treatment Nonoperative anticoagulants and thrombolytics indications login to view 1 more bullet Operative emergency immediate fasciotomy indications login to view 2 more bullets technique login to view 3 more bullets outcomes login to view 1 more bullet salvage surgery indications login to view 1 more bullet techniques login to view 7 more bullets outcomes login to view 1 more bullet Complications Most common complications: Ischemic muscle contracture muscle debridement and contracture release Fingertip gangrene Physeal distortion limb lengthening angular correction Nerve dysfunction neurolysis Prognosis Natural history of disease usually missed initially, detected only after complications ensue prognostic variable negative login to view 1 more bullet Outcomes with treatment prognostic variable favorable login to view 1 more bullet