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Difficulty: MediumPhysical Examination Findings

A 31-year-old man is evaluated in the surgical ward for severe right lower extremity pain. He was admitted four hours ago after sustaining a closed, comminuted fracture of the right tibial midshaft in a motorcycle collision. A posterior plaster splint was applied in the emergency department. The patient now reports rapidly worsening, burning pain in his right leg that is not relieved by intravenous hydromorphone. The pain is out of proportion to his initial injury. On physical examination, the right leg appears visibly swollen, and the compartments are tense to palpation. The physician suspects a developing orthopedic emergency. Which of the following specific physical examination findings is the most reliable early indicator to establish this diagnosis before irreversible tissue damage occurs?

  1. Severe pain elicited by passive plantar flexion of the right foot and toesAnswer
  2. B
    Absence of palpable dorsalis pedis and posterior tibial arterial pulses
  3. C
    Pallor and poikilothermia of the right foot distal to the fracture site
  4. D
    Complete loss of light touch sensation in the first dorsal web space
  5. E
    Inability to actively dorsiflex the right foot against gravity

Answer

Severe pain elicited by passive plantar flexion of the right foot and toes
Acute compartment syndrome is a surgical emergency caused by elevated pressure within a closed fascial space, leading to microvascular compromise and tissue ischemia. The earliest and most reliable physical examination finding is pain out of proportion to the apparent injury, which is classically exacerbated by passive stretching of the muscles within the affected compartment. In the context of a tibial shaft fracture, the anterior compartment is most frequently involved. Passive plantar flexion of the ankle and toes stretches the ischemic extensor muscles (such as the tibialis anterior and extensor digitorum longus), eliciting severe pain. Early recognition of this finding is critical to proceed with emergency fasciotomy and prevent irreversible muscle necrosis and nerve damage.

Step-by-Step Solution

1
Identify the patient's clinical presentation.
A 31-year-old man with a recent tibial fracture presents with intractable leg pain out of proportion to the injury, along with swollen and tense compartments.
Recognizing these classic symptoms is essential to suspect acute compartment syndrome.
2
Determine the pathophysiological mechanism.
Increased pressure within the unyielding fascial compartments compromises tissue perfusion, leading to muscle and nerve ischemia.
Understanding the mechanism helps in identifying which physical signs will manifest earliest.
3
Recall the chronological progression of physical examination findings in compartment syndrome.
Pain on passive stretch of the ischemic muscles occurs earliest, followed later by paresthesias, paralysis, pallor, and pulselessness.
Identifying the earliest sign is required to establish the diagnosis promptly and prevent irreversible necrosis.
4
Select the option corresponding to the earliest physical finding.
Pain elicited by passive plantar flexion of the right foot and toes is the correct finding.
Plantar flexion passively stretches the anterior compartment muscles (dorsiflexors), which is typically the earliest objective finding in tibial fracture-associated compartment syndrome.

Key Concept

Pain with passive stretch of the muscles in the affected compartment is the most sensitive and reliable early physical examination finding in acute compartment syndrome.
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Topics

Physical Examination Findings

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