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Acute compartment syndrome following closed lower-leg soft-tissue trauma — MSRA MCQ

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HardSoft Tissue InjuryAcute compartment syndrome following closed lower-leg soft-tissue traumaMSRA

A 31-year-old man attends a GP-led urgent treatment centre 2 hours after his lower leg was trapped briefly between a car bumper and a wall. He remained able to walk after the injury. Paramedics applied a firm circumferential crepe bandage because of swelling. Tibial and fibular radiographs show no fracture. Despite oral morphine, he reports rapidly worsening deep pain in the anterolateral leg that is far greater than expected from the apparent injury. The anterior compartment is tense. Passive extension of the great toe causes marked exacerbation of pain. He has new tingling in the first dorsal web space and weak toe extension. The foot is warm, with normal capillary refill and palpable dorsalis pedis and posterior tibial pulses. What is the most appropriate management now?

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

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Correct answer: C — Remove all constrictive bandaging, keep the limb at heart level and arrange immediate emergency department transfer for orthopaedic assessment

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

This is acute compartment syndrome until proved otherwise: escalating pain disproportionate to the visible injury, a tense compartment, pain on passive stretch, evolving deep peroneal nerve dysfunction and weakness are highly concerning. A normal distal pulse and capillary refill do not exclude the diagnosis; pulselessness is a late feature and should instead raise concern about associated arterial injury. The immediate priorities are to remove external constriction, avoid high elevation that may reduce perfusion pressure, maintain the limb at heart level, and transfer urgently for orthopaedic assessment and possible fasciotomy. Acute compartment syndrome requires surgery as soon as possible when present. A is unsafe because high elevation can further compromise compartment perfusion; reassessment after releasing a dressing is appropriate only within an urgent escalation pathway, not as a substitute for transfer in this clinically convincing presentation. C is plausible because unilateral swelling may suggest DVT, but the mechanism and passive-stretch pain with neurological change favour compartment syndrome. D is appropriate in diagnostically uncertain cases or when monitoring is needed, but pressure measurement must not delay urgent specialist management in a patient with strong clinical features. E risks irreversible nerve and muscle injury.

Reference: NHS: Compartment syndrome (Page reviewed 28 July 2025) — https://www.nhs.uk/conditions/compartment-syndrome/ Right Decisions NHS Borders: Orthopaedic guidelines for Hospital at Night — suspected compartment syndrome (Last reviewed 31 May 2018) — https://www.rightdecisions.scot.nhs.uk/nhs-borders-clinical-guidelines/adult-acute-services/orthopaedics/orthopaedic-guidelines-for-hospital-at-night-han/