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Difficulty: MediumSurgical and Procedural Interventions

A 34-year-old man is evaluated in the surgical telemetry unit 1212 hours after undergoing intramedullary nailing of a closed midshaft tibial fracture. He complains of rapidly worsening left leg pain that is no longer relieved by his prescribed intravenous morphine. He describes the pain as a severe, deep aching sensation. On examination, the patient appears uncomfortable and diaphoretic. Vital signs show a temperature of 37.2∘C37.2^{\circ}\text{C} (99.0∘F99.0^{\circ}\text{F}), blood pressure of 138/85 mmHg138/85 \text{ mmHg}, heart rate of 105/min105/\text{min}, and respiratory rate of 18/min18/\text{min}. The left lower leg is significantly swollen, tense, and exquisitely tender to palpation. Passive dorsiflexion and plantar flexion of the toes elicit excruciating pain. Dorsalis pedis and posterior tibial pulses are palpable and symmetric bilaterally. Capillary refill is less than 22 seconds. Which of the following is the most appropriate next step in management?

  1. Perform a four-compartment fasciotomy of the lower legAnswer
  2. B
    Measure anterior compartment pressure with a handheld manometer
  3. C
    Elevate the affected extremity above the level of the heart
  4. D
    Order a lower extremity venous duplex ultrasound
  5. E
    Increase the dose of intravenous opioids and reevaluate in one hour

Answer

Perform a four-compartment fasciotomy of the lower leg
The most appropriate next step is to perform a four-compartment fasciotomy. This patient exhibits classic signs of acute compartment syndrome (ACS), a surgical emergency characterized by elevated pressure within a closed fascial space that compromises tissue perfusion. The diagnosis is strongly suggested by pain out of proportion to the injury, a tense limb, and extreme pain with passive muscle stretch. It is critical to recognize that palpable pulses and intact capillary refill do not rule out ACS, as intracompartmental pressures rarely exceed arterial systolic pressure until the ischemia is far advanced. When the clinical diagnosis is clear, immediate surgical decompression (fasciotomy) of all four compartments of the lower leg is the required procedural intervention to prevent irreversible ischemic necrosis.

Step-by-Step Solution

1
Identify the clinical presentation as acute compartment syndrome (ACS).
The patient demonstrates pain out of proportion, a tense leg, and severe pain with passive muscle stretch following a high-risk long bone fracture.
Recognizing these classic signs is critical for diagnosing ACS, even in the presence of intact distal pulses.
2
Determine the necessity of diagnostic testing.
Diagnostic compartment pressure measurement is deferred.
The diagnosis of ACS is primarily clinical. When the classic signs are definitively present, pressure measurements are unnecessary and delay definitive treatment.
3
Select the definitive procedural intervention.
Emergent surgical decompression.
Fasciotomy is the only effective treatment to relieve intracompartmental pressure and prevent irreversible muscle and nerve ischemia.

Key Concept

The clinical diagnosis of acute compartment syndrome mandates immediate surgical fasciotomy; obtaining compartment pressures is unnecessary when clinical signs are obvious and merely delays limb-saving treatment.
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Topics

Surgical and Procedural Interventions

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