A 22-year-old male sustains a closed comminuted fracture of the right tibial shaft. Six hours after closed reduction and splinting, he complains of severe, excruciating pain in his right leg that is out of proportion to the injury and unresponsive to intravenous morphine. Passive dorsiflexion of the right toes elicits intense pain. Distal pedal pulses are palpable. What is the immediate definitive treatment?

Answer and explanation

Correct answer: D. Remove constrictive dressings and perform emergent surgical fasciotomy

  1. Step 1: The patient exhibits classical signs of Acute Compartment Syndrome of the lower leg.
  2. Step 2: Pain out of proportion to physical exam findings and pain provoked by passive stretching of the compartment muscles are the earliest and most sensitive clinical indicators.
  3. Step 3: Palpable distal pulses DO NOT rule out compartment syndrome because capillary perfusion pressure is lost long before systolic arterial pressure is compromised.
  4. Step 4: Management requires immediate release of all bandages and urgent emergent four-compartment fasciotomy to prevent irreversible muscle and nerve necrosis within 6 hours.
Answer
Remove constrictive dressings and perform emergent surgical fasciotomy.
Why not the others: 'Elevation of the leg above heart level' is contraindicated as it reduces arterial perfusion pressure to the ischemic limb; 'Application of a tight cast' worsens internal compartment pressure and causes gangrene; 'Muscle relaxants and observation' leads to amputation.

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