A 28-year-old man is evaluated in the orthopedic trauma unit 14 hours after undergoing closed reduction and casting for a displaced midshaft tibial fracture. He reports excruciating right leg pain that is rapidly worsening and no longer relieved by intravenous opioid analgesia. On physical examination, the right calf is tense and swollen. The pain is dramatically exacerbated by passive dorsiflexion of the right toes. Capillary refill is 2 seconds, and the dorsalis pedis pulse is palpable.
Arrange the following procedural and surgical steps in the most appropriate chronological order for the definitive management of this patient's acute complication.
- 1Immediate bivalving of the cast and release of all underlying circumferential dressings down to the skin
- 2Emergent surgical decompression of the lower leg via a dual-incision, four-compartment fasciotomy
- 3Application of sterile dressings or negative pressure wound therapy while leaving the fascial incisions completely open
- 4Return to the operating room after 48 to 72 hours for delayed primary wound closure or split-thickness skin grafting
Cevap
The correct chronological sequence is: 1) Immediate bivalving of the cast and release of dressings, 2) Emergent four-compartment fasciotomy, 3) Application of dressings or negative pressure wound therapy with incisions left open, and 4) Delayed primary closure or skin grafting in 48-72 hours.
The correct sequence prioritizes immediate bedside stabilization (removing the cast) followed by definitive surgical intervention (fasciotomy). Post-operatively, the wounds must be left open to accommodate swelling, with definitive closure occurring days later once the edema has resolved.
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Anahtar Kavram
The standard surgical management of acute compartment syndrome involves the immediate removal of all constricting external devices, followed by emergent multi-compartment fasciotomy with the incisions strictly left open, and concluding with delayed definitive wound closure once edema subsides.
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