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Difficulty: HardOrthopedic Surgery

A 22-year-old man is evaluated in the hospital for severe right leg pain. Ten hours ago, he underwent closed reduction and placement of a circumferential long-leg cast for a closed, displaced midshaft tibia fracture sustained during a soccer match. He states that the pain is agonizing, describes it as a deep 'burning' sensation, and reports that it has progressively worsened over the last three hours despite receiving scheduled doses of intravenous hydromorphone. On physical examination, the right foot is warm and pink. Capillary refill is 2 seconds, and the dorsalis pedis and posterior tibial pulses are palpable. He holds his ankle in slight plantar flexion. Passive dorsiflexion of the right toes elicits excruciating pain. Sensation to light touch is decreased over the first dorsal web space. Which of the following is the most appropriate initial step in the management of this patient?

  1. Immediate bivalving of the cast and division of underlying paddingAnswer
  2. B
    Measurement of lower leg intracompartmental pressures
  3. C
    Immediate preparation for four-compartment fasciotomy
  4. D
    Duplex ultrasonography of the lower extremity arterial system
  5. E
    Administration of additional intravenous opioids and elevation of the leg

Answer

Immediate bivalving of the cast and division of underlying padding
The correct answer is the immediate bivalving of the cast and division of underlying padding. This patient exhibits classic early signs of acute compartment syndrome (ACS), particularly in the anterior compartment of the lower leg. The anterior compartment contains the muscles that dorsiflex the foot and the deep peroneal nerve, which provides sensation to the first dorsal web space. Severe pain out of proportion to the injury, intense pain on passive stretch (dorsiflexion), and early sensory changes are highly specific for ACS. In any patient with suspected ACS who has a cast or circumferential dressing, the immediate first step is to relieve all external compression. Bivalving the cast and cutting all underlying cotton padding down to the skin can drastically reduce compartment pressure and may restore adequate perfusion. The limb should also be kept at the level of the heart to maximize the arterial pressure gradient.

Step-by-Step Solution

1
Identify the clinical syndrome based on the presentation.
The patient has pain out of proportion to the injury, pain with passive stretching of the muscles (dorsiflexion), and early neurologic deficits (decreased sensation in the first web space), indicating Acute Compartment Syndrome (ACS).
These are the classic early signs of ACS. The deep peroneal nerve runs through the anterior compartment and supplies sensation to the first dorsal web space.
2
Determine the most appropriate immediate intervention.
The initial step is to completely remove any external constricting forces.
Bivalving the cast and cutting all underlying padding down to the skin can reduce intracompartmental pressure by 50% to 85%, potentially averting the need for surgical fasciotomy.

Key Concept

The hallmark early signs of acute compartment syndrome are pain out of proportion to the injury and pain on passive stretch; the immediate first step in a patient with a circumferential dressing or cast is bivalving the cast and dividing all padding to the skin.
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Topics

Orthopedic Surgery

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