Compartment Syndrome: The Daily PANCE Blueprint
A 19-year-old man is seen 8 hours after a long-leg cast was placed for a tibial shaft fracture. He now has severe, relentless calf pain that is out of proportion to his injury and is not relieved by opioids. Passively extending his toes reproduces excruciating pain. The leg is tense and swollen; his distal pulses are still present and his foot is warm. Which of the following is the most appropriate next step in management?
A. Elevate the limb above the level of the heart
B. Apply ice and reassess in 2 hours
C. Order an urgent venous duplex ultrasound
D. Emergent fasciotomy
E. Repeat plain radiographs of the tibia
Answer and topic summary
The answer is D. Emergent fasciotomy
Pain out of proportion to the injury and pain on passive stretch after a fracture or cast are the earliest, most reliable signs of acute compartment syndrome — pressure rising inside a closed fascial compartment until it chokes off perfusion and threatens the muscle and nerves. The definitive treatment is emergent fasciotomy (first bivalve or remove any cast or tight dressing). The trap is that pulselessness and pallor are late findings — a warm foot with a present pulse does not rule it out, so waiting for them (or icing and observing) risks irreversible muscle death. Elevating the limb is actually wrong — elevation lowers the perfusion gradient and can worsen ischemia; keep the limb at heart level. Duplex and repeat films chase the wrong diagnosis.
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