Compartment Syndrome, ABOS Oral Boards Preparation

This is a 19-year-old male college soccer player who sustained a closed right tibial shaft fracture during a game. He was splinted at an urgent care center and transferred to our facility four hours after injury. On arrival, he was reporting escalating pain, 9 out of 10, not controlled by IV morphine. That is the key finding: pain out of proportion to the injury, refractory to narcotics.

After splint removal, the anterior compartment was tense and firm. He had severe pain with passive extension of the toes, especially the great toe. Active dorsiflexion was present but weak and painful. The lateral and deep posterior compartments were firm as well. Sensation was diminished in the first web space, the deep peroneal nerve distribution. Importantly, pedal pulses were palpable and 2+. I would not wait for loss of pulses, that is a late finding that indicates tissue death has already occurred.

Radiographs from the outside facility showed a minimally displaced transverse tibial shaft fracture at the junction of the middle and distal thirds. Fibula was intact.

Based on the clinical picture, pain out of proportion, pain with passive stretch, tense compartments, and a neurologic change, I diagnosed acute compartment syndrome. This is a clinical diagnosis. I did not need compartment pressure measurements in this case because the exam was reliable and the findings were unequivocal. I took him emergently to the operating room.

I performed a four-compartment fasciotomy through a two-incision technique. All four compartments had elevated pressures with muscle bulging upon release. The muscle was viable throughout. Through the same anesthetic, I stabilized the tibial fracture with a reamed intramedullary nail.

The fasciotomy wounds were managed with vessel loops in a shoelace pattern and negative-pressure dressings. At 48 hours, swelling had subsided significantly and I performed delayed primary closure without tension. At two weeks, wounds were healing well. At six weeks, the fracture was showing early callus. He regained near-normal strength in his anterior compartment. At four months, the fracture was healed and he was back to running. He returned to competitive soccer at six months with minimal residual symptoms.

The patient was satisfied and back to playing. In hindsight, I would have measured compartment pressures formally before taking him to the OR, even though the clinical diagnosis was clear. Having a documented delta-P in the chart strengthens the medical record, and in a case where the diagnosis is unequivocal, it only takes a moment. The clinical picture drove my decision, and it was the right call, but the documentation would have been more robust. I was watching closely for any residual anterior compartment weakness, and he recovered well.