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Zorluk: OrtaOrthopedic Surgery

A 22-year-old man is evaluated in the hospital for escalating right lower extremity pain. Eight hours ago, he sustained a closed diaphyseal fracture of the right tibia and fibula during a rugby match. The fracture was initially managed in the emergency department with closed reduction and application of a long-leg cast. The patient now describes his pain as a severe, burning ache that is "much worse than when the bone broke." He has received two doses of intravenous morphine over the past hour with no significant relief.

Vital signs are temperature 37.1°C (98.8°F), pulse 105/min, and blood pressure 135/85 mmHg.

On physical examination, the patient is visibly distressed. The visible toes of the right foot are pink, and capillary refill time is less than 2 seconds. Passive plantar flexion of the ankle and toes elicits excruciating pain in the anterior lower leg. The dorsalis pedis and posterior tibial pulses are palpable.

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

  1. Bivalve the cast and divide all underlying padding to the skinCevap
  2. B
    Elevate the right leg above the level of the heart and apply ice packs
  3. C
    Obtain computed tomography angiography of the right lower extremity
  4. D
    Measure intracompartmental tissue pressures
  5. E
    Administer an increased dose of intravenous opioid analgesia

Cevap

The most appropriate next step is to bivalve the cast and divide all underlying padding to the skin.
The correct answer involves immediately releasing the external compression. The patient exhibits classic signs of acute compartment syndrome (ACS): pain out of proportion to the injury, worsening pain refractory to strong analgesics, and excruciating pain on passive stretching of the muscles in the affected compartment (e.g., passive plantar flexion stretching the anterior compartment). It is critical to remember that palpable pulses and normal capillary refill are typically maintained until very late in ACS; their presence does not rule out the diagnosis. In any patient with a cast, splint, or tight dressing who develops signs of ACS, the immediate first step is to relieve the external pressure. Bivalving the cast (cutting it down both sides) and dividing all underlying padding down to the skin can reduce intracompartmental pressures by 65% to 90%. If symptoms do not rapidly improve after complete release of the dressing, the next step is either measurement of compartment pressures or immediate surgical fasciotomy.

Adım Adım Çözüm

1
Identify the clinical syndrome
Severe pain out of proportion to injury, pain with passive stretch, and refractory to opioids point to acute compartment syndrome (ACS).
Recognizing ACS early is critical because irreversible ischemic necrosis can occur within hours.
2
Assess the presence of external compression
The patient has a newly placed long-leg cast which acts as an unyielding external barrier, contributing to increased intracompartmental pressure.
Swelling inside a rigid cast causes compartmental pressures to rise rapidly.
3
Determine the most immediate therapeutic intervention
The external compression must be completely released by bivalving the cast and cutting the padding.
This bedside procedure immediately increases the volume of the compartment and can rapidly restore perfusion, potentially avoiding surgical fasciotomy.

Anahtar Kavram

The first step in managing suspected acute compartment syndrome in a patient with a cast or tight dressing is the immediate removal of all external compression by bivalving the cast and dividing the underlying padding to the skin.
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