A 35-year-old woman is brought to the hospital 6 hours after a road traffic accident. She has a closed fracture of the right tibia with significant soft tissue swelling but intact skin. Compartment syndrome is suspected. On examination, pain with passive stretch of the foot is present, and she reports paresthesias in the foot. What is the most appropriate immediate next step?

Explanation

## Clinical Context Compartment syndrome is a surgical emergency. The classic pentad is pain out of proportion, pain with passive stretch, paresthesias, pallor, and pulselessness — though pulselessness is a late sign. This patient has pain with passive stretch and paresthesias, which are early warning signs. ## Why Urgent Fasciotomy Without Delay is Correct **Key Point:** Compartment syndrome is a **clinical diagnosis**. Once clinical suspicion is high (pain with passive stretch + paresthesias in the setting of fracture + swelling), fasciotomy should NOT be delayed for pressure measurement. Tissue necrosis begins within 6–8 hours of ischaemia. **High-Yield:** The mnemonic for compartment syndrome management is **ACT FAST**: - **A** — Assess clinically (pain with passive stretch is the gold standard) - **C** — Clinical suspicion = surgical emergency - **T** — Time is tissue (6–8 hours to irreversible damage) - **F** — Fasciotomy immediately - **A** — Avoid delay for imaging or pressure measurement - **S** — Surgical exploration and debridement as needed - **T** — Tissue salvage depends on speed ## Why Pressure Measurement Delays Critical Care | Approach | Timing | Risk | |----------|--------|------| | Clinical diagnosis → fasciotomy | Immediate | Rare false positive; tissue saved | | Pressure measurement first | 30–60 min delay | Tissue necrosis may become irreversible | | Imaging (CT) first | 60+ min delay | **Contraindicated** — guarantees tissue loss | **Clinical Pearl:** Compartment syndrome is the one fracture complication where you **operate on clinical suspicion alone**. A fasciotomy performed "unnecessarily" (i.e., compartment pressure was borderline) is far less morbid than a missed compartment syndrome with resulting Volkmann's contracture or amputation. **Warning:** Do NOT confuse compartment syndrome with simple fracture swelling. The presence of pain with passive stretch (not just pain at the fracture site) and neurological symptoms (paresthesias) are red flags that demand immediate fasciotomy.