A 24-year-old woman is admitted to the hospital after a motor vehicle accident resulted in a right humerus fracture, multiple rib fractures, and a contusion over her right leg. The patient receives multiple packed red blood cell transfusions. Chest and abdominal evaluation show a right-sided hemothorax. A chest tube is inserted. Pain is controlled with intravenous morphine. The next morning, she has a crawling and burning sensation and worsening pain in her right leg despite repeated doses of morphine. Temperature is 37.2 C (99 F), blood pressure is 140/82 mm Hg, heart rate is 96/min, and respirations are 18/min. The right leg is swollen and tense. Pulses are palpable in both lower extremities. Which of the following is the most important determinant in this patient's prognosis?

Question

A 24-year-old woman is admitted to the hospital after a motor vehicle accident resulted in a right humerus fracture, multiple rib fractures, and a contusion over her right leg.  The patient receives multiple packed red blood cell transfusions.  Chest and abdominal evaluation show a right-sided hemothorax.  A chest tube is inserted.  Pain is controlled with intravenous morphine.  The next morning, she has a crawling and burning sensation and worsening pain in her right leg despite repeated doses of morphine.  Temperature is 37.2 C (99 F), blood pressure is 140/82 mm Hg, heart rate is 96/min, and respirations are 18/min.  The right leg is swollen and tense.  Pulses are palpable in both lower extremities. Which of the following is the most important determinant in this patient's prognosis?

Quizplus · Accepted Answer

Explanation: Signs and symptoms of compartment syndrome (CS) are unreliable, and a high index of suspicion is needed to make the diagnosis. Disease severity cannot be assessed based on clinical features alone. Time to intervention is the most important factor predicting complete functional recovery of the limb. All constrictive coverings (casts, dressings) should be removed and supplemental oxygen given. Supportive measures to maintain perfusion pressure include keeping the limb at torso level and treating hypotension if present. Fasciotomy is the definitive treatment of choice. Absence of arterial pulses (Choice A) is not a consistent finding and does not indicate a poor prognosis. Similarly, patients may have sensory deficits (Choice D) or even motor weakness but may recover completely if compartment pressure is relieved early in the disease course. Complete paralysis is a late finding, usually occurs in patients with a nonviable limb, and is generally not reversible with treatment. (Choice B) Rhabdomyolysis is a common complication of CS. However, creatine kinase level is not a prognostic indicator; such patients may have complete functional limb recovery if surgical intervention is well timed. Muscle death occurs if fasciotomy is not performed, and then limb amputation may be needed. (Choice C) The extremity may appear pale and have prolonged capillary refill with arterial occlusion from CS. Skin breakdown is a late and rare finding, usually occurring from tissue infiltration of intravenous fluids. Most patients will recover completely with early intervention. Educational objective: Clinical assessment is an unreliable indicator of disease severity in compartment syndrome. A high index of suspicion and timely fasciotomy are the most important factors predicting complete functional recovery. References: Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank. (http://www.ncbi.nlm.nih.gov/pubmed/21719009)

A 24-Year-Old Woman Is Admitted to the Hospital After a Motor