A 24-year-old male is brought to the emergency department following a motorcycle accident. He is found to have a closed comminuted fracture of the right mid-shaft tibia. The fracture is stabilized with a long-leg splint. Four hours later, the patient reports excruciating pain in his right leg that is refractory to intravenous morphine. On physical examination, the right calf is tense and exquisitely tender to palpation. There is significant pain triggered by passive extension of the great toe. Sensation is decreased in the first dorsal webbed space of the right foot. Distal pulses are 2+ and equal bilaterally.
Which of the following is the most appropriate next step in management?
The correct answer is:
E) Removal of the splint and restrictive dressings
This patient is exhibiting the classic signs of acute compartment syndrome (ACS) which include pain out of proportion to the injury, a tense wood-like feel to the limb, and pain with passive stretch. In the context of a recent fracture and splinting, the first step in management is to remove any external sources of pressure, such as tight splints, casts, or dressings. This simple maneuver can significantly reduce intracompartmental pressure. If symptoms do not immediately improve after removing the dressings, then further invasive measures or surgery are indicated.
Answer choice A: Application of an ice pack and elevation of the limb, is incorrect. While elevation is standard for most orthopedic injuries, in suspected ACS, the limb should be kept at heart level. Elevating the limb can decrease arterial inflow and further compromise perfusion pressure (Perfusion Pressure = Mean Arterial Pressure – Compartmental Pressure).
Answer choice B: Doppler ultrasound of the lower extremity, is incorrect. This is used to rule out deep vein thrombosis (DVT). While DVT can cause leg swelling and pain, the acute trauma, pain with passive stretch, and sensory deficits in this patient are much more indicative of ACS.
Answer choice C: Emergent surgical fasciotomy, is incorrect. While fasciotomy is the definitive treatment for ACS, the initial bedside management must include removing restrictive dressings. If the diagnosis remains certain or if pressure measurements remain elevated after dressing removal, the patient should then proceed to the operating room.
Answer choice D: Measurement of compartment pressures, is incorrect. ACS is primarily a clinical diagnosis. Pressure measurements are generally reserved for patients who are obtunded, have equivocal physical exam findings, or are otherwise unable to provide a reliable history. In a conscious patient with clear red flag symptoms, the diagnosis is clinical.
Key Learning Point
The initial management of suspected acute compartment syndrome involves the immediate removal of restrictive dressings or casts and keeping the limb at heart level. Following these steps, if clinical suspicion remains high or pressures are objectively elevated, emergent surgical fasciotomy is required.
