Examkin

Question

Difficulty: MediumOrthopedic Surgery

A 27-year-old collegiate athlete is evaluated on the surgical ward twelve hours after undergoing closed reduction and circumferential casting of a right tibial shaft fracture. The injury was sustained during a rugby match. Over the past two hours, he reports agonizing, unrelenting pain in his right leg that has progressively worsened despite receiving scheduled doses of intravenous hydromorphone. He states the pain feels like a "bursting pressure" and is entirely different from his initial fracture pain. On physical examination, the patient appears visibly distressed. The right foot is pink, and the dorsalis pedis pulse is easily palpable. However, passive plantar flexion of the foot and toes produces excruciating, sharp pain in the anterior leg. Sensation to light touch is diminished over the dorsal aspect of the first web space of the foot. Which of the following is the most appropriate next step in management?

  1. Immediate bivalving of the cast and division of all underlying paddingAnswer
  2. B
    Elevation of the right lower extremity above the level of the heart
  3. C
    Computed tomography angiography of the right lower extremity
  4. D
    Administration of broad-spectrum intravenous antibiotics
  5. E
    Administration of an anxiolytic and a different class of intravenous opioid

Answer

Immediate bivalving of the cast and division of all underlying padding
This patient's presentation of agonizing pain that is out of proportion to the injury, worsening despite analgesia, and exacerbated by passive stretch (plantar flexion stretching the anterior compartment muscles) is highly specific for acute compartment syndrome. The diminished sensation in the first web space indicates early ischemic dysfunction of the deep peroneal nerve, which runs through the anterior compartment. The presence of a palpable pulse does NOT rule out compartment syndrome, as capillary pressure is exceeded long before arterial pressure. The most critical immediate step in any patient developing compartment syndrome under a cast is to completely relieve all external pressure. This is accomplished by bivalving the cast and cutting all underlying padding and stockinette completely down to the skin. This simple action can reduce compartmental pressure by up to 50-85%.

Step-by-Step Solution

1
Identify the clinical syndrome from the presentation.
The patient has pain out of proportion, pain with passive stretch, and early paresthesias (diminished sensation in the first web space), which are hallmark signs of acute compartment syndrome.
Recognizing acute compartment syndrome is critical because it is a limb-threatening surgical emergency.
2
Determine the anatomical structures involved.
The deep peroneal nerve innervates the first web space and runs through the anterior compartment, confirming anterior compartment syndrome.
Localizing the affected compartment helps anticipate further complications and guides fasciotomy if conservative measures fail.
3
Select the most appropriate immediate intervention.
The first step for compartment syndrome in a casted limb is to relieve all external pressure by bivalving the cast and cutting the padding down to the skin.
This simple maneuver can significantly decrease compartmental pressure and may avert the need for an emergency surgical fasciotomy.

Key Concept

The initial management of suspected acute compartment syndrome in a patient with a cast is the immediate removal of all external compressive forces, including bivalving the cast and dividing all underlying padding down to the skin.
Rate this question

Topics

Orthopedic Surgery

More questions from this topic