A 40-year-old man has a swollen, tense and extremely painful lower leg 6 hours after a tibial fracture was placed in a plaster cast. Pain is worse on passive toe movement and analgesia is ineffective. What is the immediate management?

Answer and explanation

Correct answer: B. Release the cast and dressings and call for urgent senior surgical review for fasciotomy

  1. Step 1: Pain out of proportion and pain on passive stretch suggest compartment syndrome.
  2. Step 2: Loosening the constrictive cast is the first step, and fasciotomy is the definitive treatment if pressure remains high.
Answer
Release the cast and dressings and call for urgent senior surgical review for fasciotomy.
Why not the others: Apply ice and review him again on the next morning ward round: Waiting until morning risks irreversible muscle necrosis. Give a higher dose of opioid and elevate the leg well above heart level: Elevation lowers perfusion pressure and opioids mask a time-critical emergency. Request a venous duplex scan and start low molecular weight heparin at once: DVT is not the explanation and anticoagulation would worsen bleeding in a compartment.

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