Neurovascular assessment overview

Neurovascular observations are an essential part of the infant’s or child’s care if they present with an orthopaedic condition in order to avoid the development of Compartment syndrome, which can lead to devastating consequences. If any neurovascular compromise is detected, then prompt treatment is required.

Neurovascular assessment requires a thorough assessment of the fingers or toes on the affected limb. This assessment involves checking the 5 Ps.

• Pain
  
• Pulse
  
• Pallor
  
• Paresthesia
  
• Paralysis

Pain

Using an appropriate pain assessment tool, pain should be at the fracture site and not elsewhere. Analgesia should be given as prescribed and monitored for effectiveness.

Pulses

Radial, dorsalis pads and posterior tibialis should be assessed and grade noted. Again comparison should be made with the unaffected limb. A Doppler may be used.

Colour

The fingers or toes should be normal skin tone. Any deviation from this is suggestive of an inadequate blood flow. Comparison should be made with the unaffected limb. White, purple or blue colour is indicative of compromised blood flow.

Sensation

There should be normal sensation. Numbness and tingling (paresthesia) are not normal and may be present initially post injury or surgery due to nerve trauma. The nerve affected will be identified by the altered sensation in the relevant finger or toe. Sensation should be recorded as normal, reduced, pins and needles, partial, or moves to touch.

Movement

The child should be able to flex, extend and abduct their foot, hand, fingers and toes. This may be restricted by the plaster of Paris or the cast. Thumb-finger opposition should be present. The infant is not going to co-operate so passive assessment should be carried out.

Other indicators to be checked are:

Warmth

Compare with the unaffected digits, they should both be the same temperature when touched. If the digits are cool, then identify possible reason. How long since surgery? Is plaster of Paris still wet? Is limb exposed to the cool room temperature?

Capillary refill time

This should be <2 seconds in the digits of the affected limb. Ambient room temperature should be considered. The nail bed should be compressed for the count of 5. Normal colour should return within 2 seconds. Any time longer than this is suggestive of circulatory compromise.

Swelling

Some swelling is likely post trauma and surgery but the skin should not be shiny or taut. The limb should be elevated either by tilting the bed/cot for a lower limb or using a Bradford Sling or pillows for an upper limb injury.

Plaster/cast

Check around both top and bottom to ensure they are not too tight.

All findings should be clearly documented on the neurovascular assessment chart. The severity of the injury and type of surgery will dictate the frequency of the neurovascular assessment.