CASE BASED DISCUSSION

Chathiya Banu
27 y/o, Asian man, with u/l undisplaced left
tibial midshaft fracture

presented to ED due to increased

pain and numbness in his toes
• The fracture : the day prior
• Mechanism of fracture : NIL
1. Pre/post fracture presentation : NIL
2. Following orthopedic consult, he was
managed with long leg cast and sent home
with follow up on next day
3. Overnight, he re-presented due to worsening
and unbearable pain, PS : 10/10
Other history : unremarkable
What are the expected findings?
 Physical Examination findings
General • In pain
• Alert & conscious
• Pallor at anterior compartment
Look • No palenes/ discoloration of lt LL
Feel • Not cold
•Anterior compartment of Lt leg : tense & tenderness
upon palpation
• CRT >2 sec
• DP & PTA pulses present

Move • Increase in pain after passive stretch test

Neurovascular • Sensory : Intact
status •Motor : intact
 How do we diagnose ACS?
• Clinical signs : 6Ps
- Pain, Pallor, Parasthesia, Poikilothermia, Pulselessness, Paralysis

• Intracompartmental pressure (ICP):

- Normal : 0-10 mmHg
- Elevated : 20 mmHg
- Emergency : > 30mmHg  Fasciotomy

• Perfusion pressure/ Delta pressure : DBP – ICP

<30 mmHg  Fasciotomy
 Investigations
Aim Investigations

Pre-op workout 1. FBC

2. Coagulation profile
Complications 1. Creatinine Phospokinase : Muscle breakdown 
rhabdomyolisis
2. Renal profile / urine myoglobine / urinalysis : if
Rhabdomyolis suspected
To find out causes 1. Ultrasound : thrombus/occlusion
2. X-ray : rule out fracture
 Management?
• Complete removal of cast
• Limb : nursed flat ( elevating limb  further
reduction in end capillary pressure 
aggravates muscle ischemia)
• Keep NBM with IV NS
• Emergency Fasciotomy
 Principles of Fasciotomy
• Surgical incision complete opening to all
fascial envelopes
• Wound : left open  inspect next day
• Muscle necrosis  wound debridement
• Healthy tissues :
- Sutured without tension
- Skin grafted
- Allowed to heal by secondary intention
• Post-op
- Foot placed in neutral : prevent contracture
- Close incision : 3-5 days