20250325 Compartment syndrome - Dr Irsyad

A 32-year-old male presents with a proximal radial shaft fracture after a high-velocity trauma. He complains of severe pain despite adequate analgesia. Passive finger extension exacerbates the pain. The forearm appears tense, but capillary refill remains normal. Compartment pressure is 25 mmHg, and his diastolic blood pressure is 60 mmHg. What is the next best step in management?

• A) Observe and re-evaluate in 2 hours

• B) Remove any restrictive dressings and elevate the limb

• C) Immediate fasciotomy

• D) Start IV mannitol and bicarbonate

• E) Administer a higher dose of analgesia and reassess

Answer explanation

✅ Correct Answer:
B) Remove any restrictive dressings and elevate the limb

Explanation: In early compartment syndrome, removing constrictive bandages and elevating the limb at heart level (not above) can temporarily relieve pressure. Fasciotomy is typically performed when ΔP (diastolic BP - compartment pressure) is ≤30 mmHg. In this case, ΔP = 60 - 25 = 35 mmHg, so immediate fasciotomy may not yet be necessary.

2. Which of the following statements about Volkmann’s ischemic contracture is FALSE?

• A) It commonly results from untreated or delayed forearm compartment syndrome

• B) The most severely affected muscles are the flexor digitorum profundus and flexor pollicis longus

• C) Nerve involvement primarily affects the median and ulnar nerves

• D) Early surgical correction can fully restore function in all cases

• E) It presents with a classic claw-hand deformity due to fibrosis and contracture

Answer explanation

✅ Correct Answer:

D) Early surgical correction can fully restore function in all cases

Explanation: Volkmann’s contracture results from irreversible ischemic necrosis, leading to fibrosis and contractures of the flexor muscles. Even with early intervention, full functional recovery is rarely achieved if significant necrosis has occurred.

A patient with polytrauma develops upper limb compartment syndrome while being managed for traumatic brain injury (TBI). Which of the following factors may delay recognition of compartment syndrome in this patient?

• A) Hypotension

• B) Sedation and altered consciousness

• C) Coagulopathy

• D) Hyperkalemia

• E) Overlying soft tissue injury

Answer explanation

✅ Correct Answer: B) Sedation and altered consciousness

Explanation: Pain, the earliest and most sensitive sign, may be masked in patients with TBI, sedation, or spinal cord injury, delaying diagnosis. In such cases, serial compartment pressure measurements are crucial for early detection.

4. During an upper limb fasciotomy for acute compartment syndrome, the surgeon observes pale, non-contractile muscle tissue with a lack of bleeding after incision. What is the best intraoperative course of action?

• A) Proceed with wound closure and apply negative pressure dressing

• B) Perform additional myotomies to relieve tension

• C) Debride the non-viable muscle tissue immediately

• D) Reassess the muscle’s viability after warming and perfusion

• E) Administer IV prostacyclin and hyperbaric oxygen therapy

Answer explanation

✅ Correct Answer:

D) Reassess the muscle’s viability after warming and perfusion

Explanation: Ischemic muscle can appear pale and non-contractile initially but may recover once perfusion is restored. Surgeons should wait and reassess before extensive debridement, as premature excision of potentially viable muscle can worsen functional outcomes.

A patient undergoes fasciotomy for acute upper limb compartment syndrome. Which of the following post-operative complications is most concerning?

• A) Persistent swelling

• B) Muscle herniation

• C) Infection

• D) Nerve entrapment

• E) Rhabdomyolysis and acute kidney injury

Answer explanation

✅ Correct Answer:

E) Rhabdomyolysis and acute kidney injury

Explanation: In severe cases, muscle necrosis releases myoglobin, leading to rhabdomyolysis and potential renal failure. Early recognition and aggressive IV fluid resuscitation are critical.