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Capacitous 17-year-old refusing urgent treatment — MRCEM SBA MCQ

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HardProfessional practice and researchCapacitous 17-year-old refusing urgent treatmentMRCEM SBA

A 17-year-old attends an emergency department in England after a forearm fracture. Despite removal of a tight splint and appropriate analgesia, his forearm is tense, pain increases markedly with passive finger extension, and he has new finger paraesthesia. The orthopaedic consultant diagnoses acute compartment syndrome and advises urgent fasciotomy to prevent severe permanent hand dysfunction. The patient refuses because he does not want the resulting scar. In a discussion without his mother present, he accurately explains the operation, its alternatives and the likely consequences of refusal; he retains and weighs this information and consistently communicates his decision. His mother supports surgery. The consultant judges that an urgent court application can be made without compromising the limb, but that treatment cannot safely wait until the next day. What is the most appropriate plan?

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Correct answer: C — Seek urgent court authorisation while preparing for fasciotomy and monitoring the limb.

The tense forearm, pain on passive stretch and new paraesthesia indicate acute compartment syndrome, for which delay risks permanent nerve and muscle damage. This is therefore not a refusal that can safely be managed by observation until the next day. ([rnoh.nhs.uk](https://www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides/acute-compartment-syndrome)) The patient is 17 and has demonstrated capacity for this decision. His refusal must be taken seriously, but English consent guidance recognises that a court may override a young person’s refusal where severe permanent injury is probable. Although courts have previously accepted parental consent despite a competent young person’s refusal, the Department of Health and Social Care advises obtaining a court decision rather than relying on that consent alone. Because an urgent application is feasible without compromising the limb, the team should pursue it while preparing surgery and continuing surveillance. ([assets.publishing.service.gov.uk](https://assets.publishing.service.gov.uk/media/5a7abdcee5274a34770e6cdb/dh_103653__1_.pdf)) A fails because observation does not address the threatened irreversible injury. B relies prematurely on parental consent. D invents a reason to question an adequately assessed decision and introduces an unsafe delay. E invokes the emergency exception too soon: treatment without awaiting a court is relevant if the time needed to seek its decision would itself risk serious harm. ([assets.publishing.service.gov.uk](https://assets.publishing.service.gov.uk/media/5a7abdcee5274a34770e6cdb/dh_103653__1_.pdf))

Reference: Reference guide to consent for examination or treatment, second edition (4 August 2009) — https://assets.publishing.service.gov.uk/media/5a7abdcee5274a34770e6cdb/dh_103653__1_.pdf A Patient’s Guide to Acute Compartment Syndrome (12 November 2025) — https://www.rnoh.nhs.uk/patients-and-visitors/patient-information-guides/acute-compartment-syndrome