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Acute compartment syndrome — MCCQE Part 1 MCQ

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HardFracturesAcute compartment syndromeMCCQE Part 1

A 24-year-old man with a tibial fracture develops rapidly escalating calf pain despite opioids, pain with passive toe extension, tense swelling, and new foot paresthesia. Dorsalis pedis and posterior tibial pulses remain palpable. What is the most appropriate next step?

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Correct answer: A — Obtain immediate orthopaedic assessment for urgent decompressive fasciotomy

The combination of a high-risk fracture, pain out of proportion, pain with passive stretch, tense swelling, and evolving sensory change is acute compartment syndrome. Palpable pulses do not exclude it because tissue-level perfusion can be critically impaired while major arterial flow persists. This is a surgical emergency: remove constrictive dressings, keep the limb at an appropriate neutral level, and obtain immediate orthopaedic assessment for urgent fasciotomy. In an alert patient with a convincing clinical presentation, waiting for pressure measurement or imaging can cause irreversible delay. Pressure monitoring is useful when examination is equivocal or unreliable. Paralysis and pulselessness are late findings associated with advanced ischemic injury, not thresholds that should be awaited.

Reference: International trauma guideline update, Initial Surgical Management of Severe Lower-Extremity Injuries: https://pmc.ncbi.nlm.nih.gov/articles/PMC11666759/