Leg pain

Question 1

What are your differentials for severe leg pain and pallor?

Answer 1

Compartment syndrome
also:
- acute limb ischaemia
- DVT
- constriction of dressing/cast

Question 2

40M RTC R tib+fib #.normal obs. a/w ORIF. severe leg pain, foot pale.

How would you assess this patient?

Answer 2

1. ABCDE approach to r/o life-threatening abnormalities and ensure haemodynamic stability
2. clinically stable => focused exam of R leg. remove dressing and splint
3. HPC: SOCRATES? paraesthesia/piins and needles? location?
4. Exam: compare both sides
5. Palpate pulses, CRT, sensation, swelling/tightness, temperature
6. Move: active dorsi/plantarflexion invert/evert (paralysis). passive movement and assess for pain
7. Discuss with registrar

Question 3

What are the ‘classical’ features associated with compartment syndrome?

Answer 3

The 6 Ps are described classically as the features:
- Pain (out of proportion)
- Paraesthesia and/ or numbness
- Pallor
- Perishingly cold
- Pulseless (LATE finding)
- Paralysis (LATE finding)

Question 4

How is compartment syndrome diagnosed and treated?

Answer 4

Clinical diagnosis based on out-of-proportion pain, pain on passive stretch test, pallor and low temp. pulselessness and paralysis are late findings.

Tx: Emergency fasciotomy

Question 5

Which compartment is most likely to be involved based on the sign of pain on passive dorsiflexion of the foot?

Answer 5

Posterior compartment

Question 6

Which compartments would be decompressed with a surgical fasciotomy in this case?

Answer 6

ALL compartments (ant, lat, superficial post, deep post)

Question 7

Registrar will take 30 mins to arrive for emergency surgery. What to do?

Answer 7

Ask them if there’s anything you can do to help.
Inform:
- emergency anaesthetists
- theatre coordinator
- other ortho surgeons in case can be done earlier

Periop prep:
- reassess and optimise patient
- book emergency theatre
- d/w patient
- prepare consent form
- mark surgical site
- check bloods and crossmatch 4 units
- analgesia

Question 8

What is the NCEPOD classification of acute compartment syndrome?

Answer 8

Immediate (1B) and should be performed within minutes of the decision to operate.

B= limb saving intervention (A=lifesaving)

see table

Question 9

Why is aggressive fluid resuscitation/ management of high importance in compartment syndrome?

Answer 9

Muscle damage and ischaemia because of high compartmental pressure result in rhabdomyolysis, with resulting AKI. Fluid input/ output and, blood tests for CK and renal function should be closely monitored in these patients.

Question 10

What pressure is diagnostic of compartment syndrome?

Answer 10

within 30mmHg of diastolic BP is diagnostic