A 32-year-old male presents to the emergency department 6 hours after a crush injury to the right leg from a fallen beam at a construction site in Delhi. He complains of severe pain in the anterior compartment of the leg that is disproportionate to the clinical findings and is not relieved by analgesics. On examination, pain is elicited on passive dorsiflexion of the foot. Pedal pulses are present bilaterally. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis and Urgency **Key Point:** Compartment syndrome is a surgical emergency. The classic presentation includes the "5 P's": Pain (especially pain out of proportion and on passive stretch), Pressure, Pallor, Paresthesia, and Pulselessness (late finding). In this case, the patient has pain disproportionate to findings and pain on passive dorsiflexion—pathognomonic signs of compartment syndrome. **High-Yield:** Compartment syndrome is a **clinical diagnosis**. Waiting for investigations or attempting conservative management delays definitive treatment and risks permanent tissue necrosis, contracture, and limb loss. ## Why Fasciotomy Without Delay? **Clinical Pearl:** The window for effective fasciotomy is narrow—ideally within 6–8 hours of symptom onset. Tissue damage becomes irreversible after 8–12 hours. This patient is already 6 hours post-injury; further delay is dangerous. **Warning:** Presence of pedal pulses does NOT exclude compartment syndrome. Pulses are typically preserved until late stages because arteries lie in deeper compartments. Relying on pulse presence is a common trap. ## Management Algorithm ```mermaid flowchart TD A[Crush injury + severe pain]:::outcome --> B{Pain out of proportion?}:::decision B -->|Yes + passive stretch pain| C[Clinical diagnosis: Compartment Syndrome]:::outcome C --> D{Time since injury?}:::decision D -->|< 8 hours| E[Emergency fasciotomy]:::action D -->|> 8 hours| F[Still fasciotomy if signs persist]:::action B -->|No clear signs| G[Measure compartment pressure]:::action G --> H{Pressure > 30 mmHg?}:::decision H -->|Yes| E H -->|No| I[Conservative management + observe]:::action ``` **Key Point:** When clinical suspicion is high (as in this case), **do not delay for pressure measurement**—proceed directly to fasciotomy. Compartment pressure measurement is useful when clinical diagnosis is uncertain, not when signs are classic. ## Compartment Pressure Thresholds | Pressure Level | Clinical Action | |---|---| | < 20 mmHg | Safe; observe | | 20–30 mmHg | Borderline; consider fasciotomy if symptomatic | | > 30 mmHg | Fasciotomy indicated | | Within 30 mmHg of diastolic BP | Fasciotomy indicated (perfusion pressure criterion) | **High-Yield:** The **delta pressure** (diastolic BP minus compartment pressure) is also important—if delta < 30 mmHg, fasciotomy is indicated even if absolute pressure is < 30 mmHg.