A 32-year-old male labourer presents to the emergency department with a crush injury to his right forearm sustained 6 hours ago when a heavy metal beam fell on him. Clinical examination reveals severe soft tissue swelling, crepitus, and compartment syndrome is suspected. Plain radiographs show a comminuted fracture of the radius and ulna with multiple bone fragments. What is the most appropriate immediate next step in management?

Explanation

## Clinical Context This is a crush injury with suspected compartment syndrome — a surgical emergency requiring immediate decompression to prevent tissue necrosis, rhabdomyolysis, and renal failure. ## Why Emergency Fasciotomy is the Correct Answer **Key Point:** Compartment syndrome is a time-sensitive surgical emergency. Fasciotomy must be performed within 6–8 hours of symptom onset to prevent irreversible tissue damage. In crush injuries with comminuted fractures, compartment syndrome is a common complication. **Clinical Pearl:** The presence of crepitus and severe swelling 6 hours post-injury strongly suggests compartment syndrome. Waiting for imaging or observation risks permanent disability (Volkmann's contracture) and systemic complications (acute kidney injury from myoglobinuria). **High-Yield:** In crush injuries with comminuted fractures: - Fasciotomy takes priority over fracture fixation - Fracture stabilization can be deferred to a second stage (after soft tissue recovery) - Early fasciotomy prevents the "second hit" of reperfusion injury ## Management Sequence in Crush Injury with Compartment Syndrome | Step | Timing | Rationale | |------|--------|----------| | **Fasciotomy** | Immediate (< 6–8 hrs) | Decompress compartments, prevent tissue necrosis | | **Fluid resuscitation** | Concurrent | Prevent rhabdomyolysis-induced AKI | | **Fracture fixation** | Delayed (after soft tissue recovery) | Reduces infection risk, allows wound management | | **Reconstruction** | Later phase | After inflammation subsides | **Mnemonic:** **CRUSH** = **C**ompartment syndrome → **R**ecognize early → **U**rgent fasciotomy → **S**table fluids → **H**ealth preservation ## Why Observation or Casting Fails **Warning:** Delaying fasciotomy by even a few hours can result in: - Irreversible muscle necrosis (Volkmann's ischemic contracture) - Myoglobinuria → acute tubular necrosis - Sepsis from necrotic tissue - Loss of limb function or amputation [cite:Rockwood & Green's Fractures in Adults Ch 35]