A 28-year-old man is evaluated on postoperative day 1 after undergoing intramedullary nailing for a closed right tibial shaft fracture. Over the past 4 hours, he has developed severe, unrelenting pain in his right lower leg that is not relieved by intravenous morphine. His temperature is 37.8°C (100°F), blood pressure is 130/80 mmHg, and pulse is 108/min. On physical examination, the right leg is tense, visibly swollen, and firm to palpation. Passive plantar flexion of the toes elicits excruciating pain in the anterior leg. The pedal pulses are palpable bilaterally. Which of the following is the most appropriate next step in management?
- ATransport for computed tomography angiography of the lower extremity
- BComplete fever workup including blood and urine cultures
- CAddition of a nonsteroidal anti-inflammatory drug to the analgesic regimen
- Measurement of intracompartmental pressuresAnswer
- EInitiation of empiric intravenous broad-spectrum antibiotics
Answer
Measurement of intracompartmental pressures
The correct answer is measurement of intracompartmental pressures. This patient's presentation of severe pain out of proportion to the injury, a tense and swollen leg, and excruciating pain upon passive muscle stretch following a tibial fracture is classic for acute compartment syndrome. Because irreversible muscle and nerve ischemia can occur rapidly, prompt diagnosis is critical. Compartment pressures should be measured immediately, and if elevated, a fasciotomy must be performed. Palpable pulses do not rule out this condition, as arterial flow is often maintained until the late stages of ischemia.
Step-by-Step Solution
Key Concept
Acute compartment syndrome diagnosis and management