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Difficulty: EasySurgical and Procedural Interventions

A 32-year-old man is brought to the emergency department after a motor vehicle collision. Radiographs reveal a closed, mid-shaft fracture of the right tibia, and the patient is admitted for planned orthopedic fixation. Six hours later, he complains of severe, unrelenting right leg pain that is significantly worse than upon initial presentation. The pain is not relieved by intravenous morphine. On physical examination, the right leg is markedly swollen, tense, and exquisitely tender to palpation. There is severe pain elicited with passive dorsiflexion of the right toes. Distal pulses in the right lower extremity are currently palpable. Which of the following is the most appropriate next step in management?

  1. A
    Magnetic resonance imaging of the right lower extremity
  2. B
    Administration of therapeutic low-molecular-weight heparin
  3. Emergent four-compartment surgical fasciotomyAnswer
  4. D
    Observation until dorsalis pedis pulses become nonpalpable
  5. E
    Discharge to home with an increased dose of oral opioid analgesics

Answer

Emergent four-compartment surgical fasciotomy
This patient's clinical presentation—severe pain out of proportion to the apparent injury, poor response to opioid analgesia, a tense and swollen limb, and exquisite pain with passive stretch following a tibial fracture—is the classic manifestation of acute compartment syndrome. Acute compartment syndrome is a surgical emergency caused by elevated pressure within a closed fascial space, leading to compromised tissue perfusion. Because irreversible muscle and nerve necrosis can occur within hours, the most appropriate next step in management is an emergent four-compartment surgical fasciotomy to decompress the leg. Note that the presence of distal pulses does not rule out compartment syndrome, as arterial flow is typically maintained until the latest stages of the condition.

Step-by-Step Solution

1
Analyze the patient's symptoms and history.
The patient has a recent long bone fracture (tibia) and develops severe pain out of proportion to the injury, not relieved by standard analgesics.
Tibial fractures are the most common cause of acute compartment syndrome, making the history highly suspicious.
2
Interpret the physical examination findings.
The leg is tense and swollen, with severe pain upon passive muscle stretch (dorsiflexion of toes). Palpable pulses are still present.
Pain with passive stretch and a tense compartment are the earliest and most sensitive clinical signs of acute compartment syndrome. Pulses typically remain intact until very late in the ischemic process.
3
Determine the appropriate procedural intervention.
Identify that emergent surgical decompression is required to relieve the compartment pressure.
Failure to immediately perform a fasciotomy leads to irreversible muscle and nerve ischemia.

Key Concept

Diagnosis and acute surgical management of compartment syndrome
Estimated Time:45s
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Topics

Surgical and Procedural Interventions

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