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Difficulty: HardOrthopedic Surgery

During morning rounds, the orthopedic team evaluates a 24-year-old male who was admitted overnight following a closed mid-shaft right tibia fracture sustained during a soccer match. He was treated with closed reduction and application of a long-leg cast 88 hours ago. The patient is now highly agitated, reporting severe, throbbing pain in his right leg that has worsened significantly despite escalating doses of intravenous hydromorphone. His medical history is notable for opioid use disorder, for which he takes daily methadone. Vital signs are within normal limits. Physical examination reveals a pink, warm right foot with a capillary refill time of 22 seconds. Dorsalis pedis and posterior tibial pulses are easily palpable. However, passive plantar flexion of the toes elicits excruciating pain in the anterior shin, and the patient reports decreased sensation in the first dorsal web space. Which of the following is the most appropriate next step in management?

  1. Bivalve the cast and divide the underlying padding down to the skinAnswer
  2. B
    Measure intracompartmental tissue pressures using a handheld manometer
  3. C
    Proceed directly to the operating room for a four-compartment fasciotomy
  4. D
    Obtain an urgent computed tomography angiogram of the right lower extremity
  5. E
    Increase the methadone dose to account for baseline opioid tolerance

Answer

Bivalve the cast and divide the underlying padding down to the skin
The correct response identifies that the immediate first step for suspected acute compartment syndrome (ACS) in a patient with a cast is to remove all external constriction. Bivalving the cast and dividing the underlying padding down to the skin can drop compartment pressures dramatically (by up to 85%85\%). This action is mandatory before proceeding to invasive pressure measurements or definitive surgical fasciotomy.

Step-by-Step Solution

1
Analyze the patient's symptoms and physical exam findings.
The patient has pain out of proportion to the injury, severe pain with passive stretch (plantar flexion), and early nerve ischemia (decreased sensation in the first web space).
These findings are the classic, cardinal signs of acute compartment syndrome (ACS), which requires immediate recognition.
2
Interpret the vascular status (palpable pulses and brisk capillary refill).
Vascular status is currently intact.
Intracompartmental pressure required to cause ischemia is lower than arterial pressure, meaning pulses will remain palpable until extremely late in the course of ACS. Pulses do not rule out the diagnosis.
3
Determine the algorithmic next step for suspected ACS in a casted extremity.
The absolute first step is the release of all external circumferential constriction.
Bivalving a cast and cutting the underlying webril/padding down to the skin can reduce intracompartmental pressures by 50%50\% to 85%85\%, potentially preventing the need for surgical fasciotomy.

Key Concept

The immediate management of suspected acute compartment syndrome in a casted or splinted extremity.
Estimated Time:2m 0s
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Topics

Orthopedic Surgery

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