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Acute compartment syndrome after calf contusion — MSRA MCQ

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HardSoft Tissue InjuryAcute compartment syndrome after calf contusionMSRA

A 45-year-old man presents to a GP surgery 5 hours after a forceful direct kick to his left calf during football. At a minor injuries unit, radiographs showed no fracture and a firm elastic compression bandage was applied for a presumed calf contusion. He takes rivaroxaban for atrial fibrillation. Over the past 90 minutes, the pain has become relentless and is not relieved by paracetamol and codeine. He is unable to bear weight. The lower leg is visibly more swollen than the other side and feels tense. Passive extension of the toes produces severe calf pain. He reports new tingling over the dorsum of the foot. The foot is warm, with normal capillary refill and palpable dorsalis pedis and posterior tibial pulses. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Call 999 for emergency hospital transfer, remove the elastic bandage and pre-alert for suspected acute compartment syndrome

Explanation lettering: E = shown as A · D = shown as C · A = shown as D · C = shown as E

This is acute compartment syndrome until proven otherwise. The decisive features are rapidly escalating pain out of proportion to the apparent soft-tissue injury, a tense swollen calf, pain on passive stretch of muscles within the affected compartment, and evolving paraesthesia. Rivaroxaban increases the plausibility of bleeding into the compartment after relatively modest trauma. Normal distal pulses, capillary refill and foot temperature do not exclude the diagnosis: vascular compromise and pulselessness are late findings. Emergency transfer for urgent surgical assessment is required; external compression should be removed while transfer is arranged, but this must not become a period of observation in primary care. A is attractive because calf pain and swelling can suggest DVT, but the acute traumatic onset, tense compartment and passive-stretch pain indicate a limb-threatening alternative diagnosis. B would be appropriate only if symptoms resolved completely after relieving an excessively tight bandage and there were no compartment-syndrome features. C delays definitive assessment for imaging that is not required before escalation. E is appropriate for uncomplicated soft-tissue injury, but compression and high elevation are inappropriate when compartment syndrome is suspected.

Reference: Right Decisions: Compartment syndrome (Reviewed 4 January 2025) — https://www.rightdecisions.scot.nhs.uk/south-east-scotland-major-trauma-guidelines/orthopaedicsplastics/compartment-syndrome/ NHS: Compartment syndrome (Page last reviewed 23 April 2024) — https://www.nhs.uk/conditions/compartment-syndrome/