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Difficulty: HardSurgical and Procedural Interventions

A 24-year-old male is evaluated in the orthopedic unit for severe left lower leg pain 12 hours after undergoing open reduction and internal fixation of a comminuted midshaft tibia fracture. He describes the pain as a "10/10" burning sensation that is significantly worse than his preoperative pain. The pain is not relieved by escalating doses of intravenous hydromorphone. On physical examination, the left lower leg is visibly swollen, and the skin is tense and shiny. Passive dorsiflexion of the toes elicits excruciating pain. Sensation to light touch is decreased over the first dorsal web space. Dorsalis pedis and posterior tibial pulses are equal and brisk. Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

  1. Immediate removal of all encircling dressings and splints down to the skinAnswer
  2. Emergent four-compartment fasciotomy of the affected extremityAnswer
  3. C
    Elevation of the affected extremity above the level of the heart
  4. D
    Computed tomography angiography of the lower extremity
  5. E
    Initiation of a continuous intravenous heparin infusion

Answer

The most appropriate next steps are the immediate removal of all encircling dressings and splints down to the skin, followed by an emergent four-compartment fasciotomy of the affected extremity.
This patient presents with classic signs of acute compartment syndrome (ACS) of the lower leg following a tibial fracture repair. The clinical hallmarks of ACS include pain out of proportion to the injury, pain exacerbated by passive stretch of the involved muscles, tense compartments, and paresthesias. Importantly, normal distal pulses are typically maintained until the very late stages of ischemia, as the pressure required to occlude capillary and venous flow is significantly lower than arterial systolic pressure. When ACS is clinically evident, management requires two immediate procedural interventions. First, any external compressive forces must be eliminated by completely removing dressings, bivalving casts, and cutting padding down to the skin. This simple maneuver can reduce compartment pressure significantly. Second, because the patient has unequivocal signs of ACS including a focal neurological deficit (deep peroneal nerve territory), definitive treatment requires emergent surgical decompression via a four-compartment fasciotomy.

Step-by-Step Solution

1
Analyze the clinical presentation
The patient has severe pain out of proportion to injury, pain with passive stretch, tense leg swelling, and paresthesias (decreased sensation in the first web space) following a high-risk tibia fracture.
These findings are the classic clinical hallmarks of acute compartment syndrome.
2
Interpret the presence of distal pulses
Dorsalis pedis and posterior tibial pulses are present.
Palpable pulses do not rule out compartment syndrome, because microvascular capillary bed occlusion occurs at much lower pressures than major arterial occlusion.
3
Determine the necessary initial and definitive interventions
First, remove external compression. Second, perform surgical decompression.
Bivalving casts and removing dressings can drop compartment pressure by up to 85%. Since the patient has an unequivocal clinical presentation with neurologic deficits, emergent fasciotomy is definitively required without delay.

Key Concept

Acute compartment syndrome is a surgical emergency diagnosed clinically by pain out of proportion to injury, pain on passive stretch, and tense compartments. Management requires immediate removal of external constraints and emergent surgical fasciotomy, strictly avoiding limb elevation.
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Topics

Surgical and Procedural Interventions

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