Practice Lesson of the week

Amputation and intraosseous access in infants

BMJ 2011; 342 doi: (Published 27 May 2011) Cite this as: BMJ 2011;342:d2778
  1. Colm C Taylor, senior clinical fellow ,
  2. N M P Clarke, consultant orthopaedic surgeon
  1. 1Southampton General Hospital, Tremona Road SO16 6YD, UK
  1. Correspondence to: N M P Clarke ortho{at}
  • Accepted 15 March 2011

Place intraosseous needles carefully and limit fluid infusion to avoid limb ischaemia in children

Vascular access in critically ill children is a priority for emergency administration of fluid and therapeutic agents. Intraosseous access is an alternative when attempts at venous access fail.1 The proximal tibia is the preferred site for intraosseous needle insertion, with an accessible subcutaneous cortex. Manual insertion of the intraosseous needle can be supplemented with approved impact driven and power driven needle systems.2

Intraosseous access has low failure and complication rates,3 but compartment syndrome has been reported in association with this procedure,4 and preventive measures have been recommended.5 Three cases of amputation have been reported, preceded by clinical features of compartment syndrome within a few hours of admission.6

We describe two cases of leg amputation after intraosseous infusion to emphasise the risk of limb ischaemia during paediatric resuscitation by this route.

Case reports

Case 1

A 5 month old girl was resuscitated at a local hospital for pulseless cardiac arrest caused by unrecognised congenital diaphragmatic hernia. Emergent bilateral proximal tibial intraosseous access was achieved with a power driven system. Resuscitation included 1:10 000 adrenaline solution, 200 mL normal saline, 15 mmol sodium bicarbonate, 10 µg/kg dopamine infusion, and whole blood. In total over 400 mL of solution was infused, predominantly through the left leg. She was transferred for laparotomy, and subsequent ventilatory and inotropic support in the paediatric intensive care unit. Both distal lower limbs were pale but not tense on admission; by day seven, the right limb was perfused but her left leg had become demarcated with notable mottling to mid-calf level (figure 1). Bilateral posterior tibial fractures were noted at the level of intraosseous access. The patient was taken to theatre on day 12; all lower limb compartments were explored but were non-viable and an amputation was performed below the knee. She had no further sequelae and was discharged at one month. At six months, her right lower limb had no deficit and extension at the left knee was maintained.

Case 2

A 17 month old boy attended a local hospital 48 hours after a scald injury to the chest with a truncal rash and deteriorating consciousness. Bilateral proximal tibial intraosseous access was established with a power driven system. Resuscitation included 250 mL normal saline/dextrose saline, 300 mL 4.5% albumin solution, 8.4% sodium bicarbonate calcium gluconate, and whole blood. Fluid distribution between the limbs was unclear, but intraosseous infusion was increasingly difficult on the right side within 30 minutes, the left being used exclusively after this. Total infused volume was 730 mL. On transfer to the paediatric intensive care unit, the left leg was tense and pulses were impalpable bilaterally. During treatment for septicaemia, the patient’s left limb gradually demarcated to proximal calf at the lateral aspect, while perfusion returned on the right. A below knee amputation was performed on day 13, when all muscle compartments were non-viable. He was discharged at six weeks. The limb had made good progress by six months, with early prosthetic fitting; unfortunately early signs of distal tibial physeal arrest were seen at the right lower limb.


Local tissue necrosis and osteomyelitis were described in the earliest report on the complications of intraosseous infusion in 1945.7 Sternal and tibial access was preferred and contemporary guidelines emphasised careful needle insertion and avoiding prolonged infusion times.

Several recent case reports have described compartment syndrome after intraosseous access. Large infusion volumes have been implicated, and animal studies report microcirculatory fluid leak in both dose-dependent and time-dependent mechanisms.8 Other potentiating factors include needle dislodgement, penetration through the posterior cortex, and leaking through previous potentiating access sites.5 Both patients described here had prolonged resuscitation incorporating large amounts of fluid and potentially irritating therapeutic solutions. Failure of peripheral access necessitated continued use of intraosseous infusion, potentiating the risk of extravasation, particularly as venous return is greatly diminished in paediatric resuscitation. Guidelines regarding intraosseous infusions were published by the American Academy of Pediatrics in 1994; these suggested limiting the time of infusion, securing definitive peripheral access, avoiding infusion pumps, and careful observation of the limb during early infusion.9

Progression to amputation was first described in 1990, when a 3 month old child had an amputation at the knee after prolonged resuscitation.6 A further three cases have been described, all during prolonged infusion, with the earliest recognition of compartment syndrome at 2.5 hours into resuscitation. Three patients had infusion of potentially irritating solutions, including inotropes, sodium bicarbonate, and calcium. Two patients were transported with intraosseous needles in situ.

Although power driven needle systems are rapid in establishing access, the potential for inaccurate needle placement remains, because children’s tibia have a small cross-sectional area available for effective access.9 10 Resulting paediatric tibial fractures, as in case 1, have previously been reported, and particular care needs to be taken with infants.11 Insecure access and needle dislodgement allowed unrecognised extravasation in case 2; securing an accurately placed needle is especially important during transfer, and use of a threaded needle has been suggested.12

We conclude that fluid extravasation, exacerbated by tibial fracture and needle dislodgement during transportation, caused limb ischaemia in these two patients. Local chemical necrosis and peripheral hypoperfusion were potentiating factors. Where ventilation and fluid resuscitation is a priority, impending compartment syndrome is easily missed. Early recognition allows our preferred option of subcutaneous fasciotomy in the young child. Adherence to the principles detailed in the BMJ almost 70 years ago (figure 2) 13 of careful needle placement, splinting, limited length of infusion and repeated monitoring of the limb will help avoid this devastating complication.


Cite this as: BMJ 2011;342:d2778


  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.