Acute compartment syndrome following tibial fracture fixation — MRCEM SBA MCQ

Instant feedback + full explanation. One question, done properly.

HardTraumaAcute compartment syndrome following tibial fracture fixationMRCEM SBA

A 27-year-old man is assessed 8 hours after intramedullary nailing of a closed tibial shaft fracture. Postoperative radiographs show satisfactory alignment. He is alert and normotensive and has not received a regional nerve block. Despite intravenous opioid analgesia, he has escalating calf pain, marked pain on passive extension of the toes and new reduced sensation on the sole of the foot. The foot is warm, with palpable pedal pulses. All circumferential dressings are removed, the leg is kept at heart level and he is reassessed 30 minutes later; the findings are unchanged. The orthopaedic team and operating theatre are available. What is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: A — Arrange urgent four-compartment fasciotomy of the leg.

This is a clear clinical presentation of acute compartment syndrome after tibial fracture fixation: pain is escalating despite analgesia, passive toe movement provokes marked pain, and sensation has changed. Palpable pulses do not exclude compartment syndrome. The findings persist after circumferential dressings have been removed and the limb has been kept at heart level, so urgent orthopaedic surgical decompression is the next step. Lower-leg decompression should release all four compartments. ([rightdecisions.scot.nhs.uk](https://www.rightdecisions.scot.nhs.uk/south-east-scotland-major-trauma-guidelines/orthopaedicsplastics/compartment-syndrome/?utm_source=openai)) B is attractive because compartment pressure monitoring has a role after tibial fracture, but NICE particularly recommends considering it when symptoms and signs cannot readily be assessed, such as in an unconscious patient or one with a nerve block. Here the examination is reliable and the clinical diagnosis is clear; measurement should not defer surgery. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations)) C would investigate suspected arterial injury, but the predominant findings are characteristic of compartment syndrome, not a pulseless ischaemic limb. D would address failed alignment or fixation, neither of which is evident on the postoperative films. E may provide analgesia but would not relieve compartment pressure and could make serial clinical assessment harder. Acute compartment syndrome requires prompt fasciotomy. ([rightdecisions.scot.nhs.uk](https://www.rightdecisions.scot.nhs.uk/south-east-scotland-major-trauma-guidelines/orthopaedicsplastics/compartment-syndrome/?utm_source=openai))

Reference: Fractures (complex): assessment and management, recommendation 1.2.7 (23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations South East Scotland Major Trauma Guidelines: Compartment syndrome (Last reviewed 4 January 2025) — https://www.rightdecisions.scot.nhs.uk/south-east-scotland-major-trauma-guidelines/orthopaedicsplastics/compartment-syndrome/ NHS: Compartment syndrome (Last reviewed 4 September 2026) — https://www.nhs.uk/conditions/compartment-syndrome/