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Difficulty: MediumOrthopedic Surgery

A 32-year-old recreational skier is admitted after sustaining a closed diaphyseal fracture of the right tibia. Following closed reduction and immobilization in a circumferential long-leg cast, he is monitored on the orthopedic ward. Fourteen hours later, he develops excruciating leg pain that worsens with passive movement and is entirely refractory to high-dose intravenous analgesia. Arrange the following clinical steps in the appropriate chronological sequence for the definitive management of this patient's evolving condition.

  1. 1Perform a targeted physical examination to confirm pain with passive stretch of the toes.
  2. 2Remove all external compression by splitting the cast and cutting the inner padding down to the skin.
  3. 3Perform an emergency surgical decompression of all four fascial compartments of the leg.
  4. 4Apply non-adherent sterile dressings or negative pressure wound therapy to the open surgical sites.
  5. 5Return the patient to the operating room for delayed primary wound closure or skin grafting.

Answer

The correct chronologic sequence is: 1) Clinical confirmation via passive stretch, 2) Release of external compression (splitting the cast), 3) Emergency multi-compartment fasciotomy, 4) Temporary open wound management, and 5) Delayed primary wound closure.
Acute compartment syndrome is a surgical emergency characterized by elevated pressure within a closed osteofascial space. The chronologic management begins with clinical recognition (pain out of proportion, pain with passive stretch). The immediate next step is relieving any external compression by completely splitting the cast and cutting all inner dressings down to the skin. If symptoms do not rapidly resolve, definitive treatment is an emergency multi-compartment fasciotomy. Post-operatively, the wounds must be left open and managed with sterile dressings or negative pressure therapy to allow for continued muscle swelling. Finally, once tissue edema subsides days later, delayed primary closure or skin grafting is performed.

Step-by-Step Solution

1
Evaluate the patient clinically for signs of elevated intracompartmental pressure.
Identification of severe pain with passive stretch confirms the high clinical suspicion of acute compartment syndrome.
Early clinical recognition is crucial because irreversible nerve and muscle damage can occur within a few hours of onset.
2
Relieve any potential external sources of limb compression.
The long-leg cast and all underlying cotton padding are split completely down to the skin.
External restrictions drastically increase compartmental pressure. Complete removal of a cast and padding is a rapid intervention that can lower pressure by up to 85%.
3
Proceed to the operating room for definitive emergency decompression.
A four-compartment fasciotomy of the lower extremity is executed.
Definitive management of acute compartment syndrome requires incising the fascial compartments to allow muscle expansion, thereby restoring vital capillary perfusion.
4
Manage the open fasciotomy incisions post-operatively.
Negative pressure wound therapy or bulky sterile dressings are applied to the open wounds.
Fasciotomy incisions cannot be closed acutely because the reperfused muscle will continue to swell; attempting primary closure would trap the muscle and recreate the compartment syndrome.
5
Perform definitive soft tissue coverage of the lower extremity.
Delayed primary closure or split-thickness skin grafting is performed.
Once the acute inflammatory phase passes and edema resolves (typically 2-3 days later), the skin can safely be closed to prevent infection and promote healing.

Key Concept

Acute Compartment Syndrome Management Sequence
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Topics

Orthopedic Surgery

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