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Acute lower-leg compartment syndrome after tibial fracture fixation — MRCEM SBA MCQ

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HardTraumaAcute lower-leg compartment syndrome after tibial fracture fixationMRCEM SBA

A 27-year-old man returns to the emergency department 30 hours after intramedullary fixation of a closed tibial shaft fracture sustained in a motorcycle collision. He is alert and has not received a nerve block. Over the past two hours, pain in the injured leg has escalated despite intravenous opioid analgesia. The calf is tense, passive movement of the toes causes marked pain, and sensation in the first dorsal web space is reduced. His foot is warm, with palpable dorsalis pedis and posterior tibial pulses. Circumferential dressings were removed down to the skin 30 minutes ago, without improvement. An orthopaedic surgeon and an operating theatre are available. What is the most appropriate next step?

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

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Correct answer: B — Proceed to emergency fasciotomy of the injured leg.

This is a clinically clear acute compartment syndrome following tibial fracture fixation: escalating pain despite analgesia, marked pain on passive stretch, a tense calf and new sensory disturbance persist after removal of potentially constrictive dressings. The presentation remains within the 48-hour period after fixation during which NICE advises vigilance for compartment syndrome. Palpable distal pulses do not exclude it. Urgent surgical decompression is therefore the priority. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations)) A is attractive because NICE advises considering continuous pressure monitoring when symptoms and signs cannot readily be identified, such as in an unconscious patient or one with a nerve block. This patient is alert, examinable and has convincing clinical findings; monitoring must not delay treatment. C would be appropriate if the findings suggested arterial injury, but a warm, pulsed foot and the characteristic pain pattern point instead to compartment syndrome. D is appropriate surveillance for a patient *at risk* who has not developed convincing signs, not for this patient. E addresses external constriction and would have been an appropriate initial manoeuvre, but the dressings have already been removed without relief. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations))

Reference: NICE NG37: Fractures (complex): assessment and management, recommendation 1.2.7 (23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations Royal National Orthopaedic Hospital: 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 BMJ Best Practice: Compartment syndrome of extremities (Updated 23 November 2023; evidence reviewed August 2026) — https://bestpractice.bmj.com/topics/en-us/502