Patient Presentation

A 33-year-old male (SM) is post-op day 0 s/p open reduction internal fixation (ORIF) for a tib/fib fracture he sustained from a ski injury. He in the recovery room and just returned back to bed after dangling at the edge with the Physical Therapist for the first time.  SM is a healthy, active young man with no past medical history. Prior to Physical Therapy, he rated his pain VAS 6/10 (visual analog scale) and reported that his sensations were returning as his nerve block was wearing off.  He could wiggle his toes, had positive palpable dorsalis pedis and anterior tibial pulses, his toes were warm to touch, capillary refill brisk, and had positive swelling consistent with recent fracture/surgery. Neurovascular checks are done every hour for the first 4 hours post-op then every 2 hours for the next 24 hours. After Physical Therapy, SM reported that his pain was now a VAS 10/10. He was crying, clutching the bed rails with his hands and yelling.  Vitals at this time BP 138/88, HR 104, RR 24, O2 Sat 98% on 3L Nasal Cannula, Temp 37.8.  The RN repositioned the leg high on pillows and pushed Dilaudid 1mg IV x3 with no relief in pain.  Neurovascular status is still intact but the patient is now screaming, complaining that the “pain is ripping my leg apart”.  The RN contacted the Surgical Team to come see the patient stat for further assessment.

Differential Diagnosis

Uncontrolled post-operative pain, Reflex Sympathetic Disorder, Compartment Syndrome, Drug-seeking behavior, Cellulitis (Necrotizing Fasciitis), Deep Vein Thrombosis

Diagnosis

When the resident arrived to the patient’s bedside, he pulled apart the ace wrap and supportive plaster mold underneath in order to palpate the patient’s calf which was firm, very warm to touch and tender. He gently passively dorsiflexed the foot and the patient screamed louder.  The resident knows that the “5P’s” associated with Compartment Syndrome (the first symptom being Pain out of proportion, unrelieved by pain relievers; Parasthesia (late sign); Pallor; Parasthesia; Pulselessness) and immediately the Resident asked for a Stryker Needle which is used to measure compartment pressures >30mmHg (elevated).  There are 5 compartments in the lower leg and when there is increased pressure in one or more, it can lead to muscle, nerve, and circulatory damage. The fascia which covers compartments of muscle, nerves, and blood vessels don’t expand so any increased swelling inside presses on the contents of the compartments causing decreased flow to these tissues and buildup of waste products in the area.

Treatment

Treatment is based on early decompression of the compartments’ building pressure.  If the pressure remains >30mmHg, the patient will develop vascular compromise and necrosis within hours.  SM was immediately brought back to the OR, all bandages were removed and a fasciotomy was done.  A fasciotomy involves cutting incisions lengthwise to relieve pressure in the lower leg, allowing the compartments to expand and vascular flow to be restored.   These wounds are left open with sterile dressings or covered by a wound VAC and re-closed usually 48-72 hours later (sometimes skin grafts are needed to close).

Outcome

Prognosis of compartment syndrome depends on early diagnosis, treatment, and relief of pressure.  If a fasciotomy is delayed, nerve and muscle injury can be permanent but typically the prognosis is good if treated early and the patient should regain all function. With the open wound, there is a high risk of infection so meticulous, sterile wound care is imperative until it is closed.

Case created by Sarah Metz, 2011.