A 22-year-old man involved in a motor vehicle collision undergoes a prolonged surgery to repair a left tibial fracture and popliteal artery injury. The day after surgery he has increasing pain in the left leg and is treated with intravenous fluids and morphine. Two hours later, the patient continues to have pain that worsens with passive leg movement and has a "pins and needles" sensation. Examination shows tense, tender swelling of the left calf. There is sensory loss between the great and second left toes. The lower-extremity pulses are palpable bilaterally. Which of the following is the most important next step in management of this patient?

Question

A 22-year-old man involved in a motor vehicle collision undergoes a prolonged surgery to repair a left tibial fracture and popliteal artery injury.  The day after surgery he has increasing pain in the left leg and is treated with intravenous fluids and morphine.  Two hours later, the patient continues to have pain that worsens with passive leg movement and has a "pins and needles" sensation.  Examination shows tense, tender swelling of the left calf.  There is sensory loss between the great and second left toes.  The lower-extremity pulses are palpable bilaterally.  Which of the following is the most important next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d967_3847_bc81_e50338509fe6_MD0003_00 Compartment syndrome (CS) can be caused by direct trauma or prolonged compression of an extremity or after revascularization of an acutely ischemic limb. Patients typically have excruciating pain that is worsened on passive range of motion and does not respond well to narcotics. There is considerable variation in associated signs and symptoms, and a high index of suspicion is needed to make a diagnosis. Paresthesia from sensory nerve ischemia is usually an early finding. Neurologic deficits (eg, sensory loss, motor weakness) may be present but develop later in the course of the disease. Pallor is the result of arterial occlusion but is uncommon and not required for diagnosis. Similarly, arterial pulses are present in a majority of patients, especially in early stages of CS. Diagnosis can be confirmed by measuring compartment pressures in the affected extremity. However, in high-risk patients (eg, those with limb revascularization) who develop symptoms suggestive of CS (pain, swelling, sensory loss), the diagnosis may be made on clinical grounds alone. Time to fasciotomy is the most critical prognostic indicator and should be performed without delay. (Choice A) Supportive measures should be taken to maintain perfusion pressure in the extremity, which includes keeping the leg at the level of the torso (not higher or lower). Leg elevation and ice would be recommended if leg edema were secondary to inflammation (eg, cellulitis). (Choice B) Increased analgesic dosages may be needed to control increasing pain. However, surgical intervention is of utmost importance to preserve limb function. This patient's neurologic symptoms and tense swelling highly suggest developing CS rather than simple postsurgical changes. (Choice C) Deep venous thrombosis (DVT) is diagnosed with Doppler ultrasonography. Like CS, DVT may also present with increasing pain and swelling, but symptoms are more insidious in onset and less severe. The presence of neurologic symptoms makes CS more likely, especially in a patient who is predisposed. (Choice D) X-rays of the lower extremity would be needed if there was evidence of fracture displacement (leg shortening, rotation, and angulation). Educational objective: Patients with compartment syndrome have severe pain, pain with passive range of motion, and paresthesia. Sensory and motor deficits occur in later stages. Pallor and loss of limb pulses are uncommon findings. Compartment pressures must be measured immediately if the index of suspicion is very high. Fasciotomy is the treatment of choice. References: Compartment syndrome of the lower leg and foot. (http://www.ncbi.nlm.nih.gov/pubmed/19472025)

A 22-Year-Old Man Involved in a Motor Vehicle Collision Undergoes