Acute Compartment Syndrome of the Leg

My immediate approach:

1. History (at bedside within minutes):

• Character of pain: Is it constant, severe, worsening despite analgesia?
• Location: Is it in the calf/leg beyond the fracture site?
• Associated symptoms: Numbness, tingling, weakness?
• Compare to earlier post-op pain level

2. Immediate actions before examination:

• Remove ALL circumferential dressings - split any cast to skin
• Position limb at heart level

3. Examination:

• Palpate all four compartments - are they tense and woody?
• Pain on passive stretch - plantarflex foot (anterior), dorsiflex (posterior)
• Sensory testing - first web space (deep peroneal), dorsum of foot (superficial peroneal)
• Motor testing - EHL, tibialis anterior, toe flexion
• Pulses - but I recognize these are usually present in compartment syndrome

4. Decision:

• If clinical features are convincing (pain out of proportion, passive stretch pain, tense compartments) - proceed DIRECTLY to four-compartment fasciotomy
• If equivocal - measure compartment pressures in all four compartments
• Calculate Delta P = diastolic BP minus compartment pressure
• Delta P less than 30mmHg = indication for fasciotomy

5. Consent and theatre:

• Explain urgency and risk of permanent damage if delayed
• Consent for fasciotomy, possible muscle debridement, wound left open, possible skin graft, acknowledge rare risk of amputation
• Theatre should be available within 30-60 minutes maximum

Two-incision, four-compartment fasciotomy technique:

Patient positioning: Supine with bump under ipsilateral hip, entire leg prepped and draped.

Lateral incision (releases anterior and lateral compartments):

• Incision 2cm anterior to fibula, from fibular head to lateral malleolus
• Full-length skin incision - don't be conservative
• Identify intermuscular septum between anterior and lateral compartments
• Incise lateral compartment fascia longitudinally
• Identify and protect superficial peroneal nerve in distal third
• Pass anterior to septum, incise anterior compartment fascia
• Confirm muscles are bulging and viable (pink, contractile)

Medial incision (releases superficial and deep posterior compartments):

• Incision 2cm posterior to medial tibial border, from tibial tuberosity to medial malleolus
• Identify and preserve great saphenous vein and saphenous nerve
• Incise superficial posterior compartment fascia over gastrocnemius
• For deep posterior: detach soleus from its tibial origin
• This exposes the fascia of deep posterior compartment
• Incise deep posterior fascia, protecting posterior tibial neurovascular bundle

Completion:

• Assess all muscle for viability - debride any necrotic tissue
• Thorough washout
• Leave wounds OPEN - do not close
• Apply VAC dressing or moist gauze with vessel loop approximation
• Plan return to theatre at 24-48 hours for second look
• Delayed primary closure or STSG at 3-5 days

This is a critically important clinical and ethical situation:

Key considerations:

• Time elapsed: At 24 hours, irreversible necrosis has almost certainly occurred. The 6-8 hour window is long passed.
• Clinical findings: Fixed claw deformity, no pulses, complete sensory loss suggest non-viable tissue.
• Risk of fasciotomy in non-viable tissue: Reperfusion of necrotic muscle releases massive amounts of potassium, myoglobin, and inflammatory mediators causing life-threatening hyperkalemia, acute renal failure from myoglobinuria, systemic inflammatory response, and potential cardiac arrest.

My recommendation:

• Fasciotomy is NOT indicated for established necrosis at 24+ hours
• Instead, the patient needs honest discussion about likely amputation
• Obtain urgent vascular surgery opinion
• Assess for systemic effects (CK, K+, renal function)
• Supportive care for rhabdomyolysis if present
• Early amputation may be life-saving if systemic toxicity is developing

If uncertain about viability:

• Angiography may help assess vascular status
• If any question of salvageability, take to theatre for exploration under controlled conditions
• Be prepared for immediate amputation if limb is non-viable
• Have ICU available for post-operative care

Documentation: Meticulously document the clinical findings, timing, discussions with patient and family, and rationale for management decisions.

Compartment syndrome is one of the most litigated conditions in orthopaedics.

Key medicolegal issues:

• Missed diagnosis: Most common allegation - failure to recognize or delayed diagnosis
• Inadequate monitoring: Failure to implement appropriate post-operative surveillance
• Documentation gaps: Poor documentation of neurovascular exams
• Communication failures: Not communicating with nursing staff about warning signs

Protection strategies:

• Document baseline: Record detailed neurovascular status at presentation
• Time-stamp everything: Shows vigilant monitoring
• Clear clinical findings: Document pain quality, passive stretch response, compartment tension
• Record interventions: Cast splitting, elevation, pressure measurements with actual values
• Communication: Document discussions with patient and family about risks
• Clear indication: If proceeding to surgery, document why clearly
• Comprehensive consent: Include amputation as possible outcome if delayed presentation
• Nursing communication: Written instructions on monitoring protocol and escalation triggers

Red flags that increase liability:

• Regional anesthesia masking pain (document if used)
• Obtunded patient without pressure monitoring
• Gaps in neurovascular documentation
• Delayed response to nursing concerns