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Difficulty: MediumSurgical and Procedural Interventions

Following an open reduction and internal fixation for a comminuted right tibial diaphysis fracture, a young adult patient is evaluated on the surgical ward for intractable lower extremity pain. The operative procedure was completed 14 hours ago. The overnight nursing staff reports that the patient has required multiple breakthrough doses of intravenous hydromorphone with minimal relief.

The patient describes the pain as a severe, deep burning sensation in the right calf that is significantly worse than his preoperative pain. On physical examination, the right leg is markedly swollen, and the anterior compartment feels exceptionally tight and woody to palpation. Passive plantar flexion of the right ankle elicits agonizing pain. Dorsalis pedis and posterior tibial pulses are 2+ and symmetric with the left foot. Capillary refill is less than 2 seconds in the right toes, but the patient reports decreased sensation to light touch in the first dorsal web space. All compressive dressings and bandages have already been completely removed down to the skin, with no improvement in symptoms.

Which of the following is the most appropriate next step in management?

  1. A
    Elevation of the right leg above the level of the heart
  2. B
    Measurement of intracompartmental pressures
  3. Immediate multi-compartment fasciotomyAnswer
  4. D
    Lower extremity venous duplex ultrasonography
  5. E
    Measurement of the ankle-brachial index

Answer

Immediate multi-compartment fasciotomy
The correct answer is immediate multi-compartment fasciotomy. The patient presents with textbook signs of acute compartment syndrome (ACS) of the anterior compartment of the lower leg: severe pain out of proportion to the injury, pain with passive stretch (plantar flexion), tense/woody swelling, and paresthesias in the distribution of the deep peroneal nerve (first dorsal web space). Because the clinical diagnosis is unequivocal and the initial non-surgical step of removing all constrictive dressings has already been completed, emergent surgical decompression via fasciotomy is definitively indicated to prevent irreversible tissue necrosis.

Step-by-Step Solution

1
Recognize the clinical signs of acute compartment syndrome (ACS).
The patient has pain out of proportion to the injury, severe pain on passive stretch of the affected muscles (plantar flexion stretches the anterior compartment), woody tissue tension, and early neurological deficits (decreased sensation in the first web space via the deep peroneal nerve).
These classic indicators strongly point to ACS. Notably, bounding pedal pulses remain present because compartmental pressure rarely exceeds systolic arterial pressure, meaning pulselessness is a very late and often irreversible sign.
2
Determine the necessity of diagnostic testing versus immediate intervention.
Because the clinical diagnosis is unambiguous and all restrictive dressings have already been removed, immediate surgical intervention is indicated without further confirmatory testing.
Delaying treatment to measure intracompartmental pressures in a clinically obvious case increases the risk of irreversible ischemic muscle contracture and nerve necrosis.
3
Select the definitive management step.
A multi-compartment fasciotomy is required immediately.
Fasciotomy is the definitive treatment, as it immediately relieves the elevated intracompartmental pressure and restores microvascular perfusion to the affected tissues.

Key Concept

In patients with unequivocal clinical signs of acute compartment syndrome (pain out of proportion, pain on passive stretch, woody induration, paresthesias), immediate fasciotomy is the treatment of choice and should not be delayed for compartment pressure measurements.
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Topics

Surgical and Procedural Interventions

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