There’s a number of things that you need to be concerned about
as complications of extremity injuries
and you always wanna consider these things
when patients represent with worsening of pain
or worsening symptoms after an extremity injury.
Compartment syndrome is number one but you also wanna think about the possibility
that there is a neurovascular injury that was missed on the initial presentation.
You wanna think about the possibility of venous thromboembolism,
arterial occlusion or infection in the case of open fractures, lacerations, et cetera.
You always wanna make sure before the patient is discharged the first time
that they’re aware of these complications and they know what to look for.
So you wanna tell them what symptoms should prompt them
to return to the Emergency Department.
It’s very, very important so they don’t sit home thinking that all this is normal.
In our case, we’re concerned about compartment syndrome
which is caused by increased pressure in a closed space.
Now compartments in the extremities are basically delineated by fascia
which is non-distensible fibrous tissue.
So when you have a lot of swelling or edema within a compartment,
the compartment can’t stretch out to accommodate that
which is gonna lead to increased compartment pressures
and ultimately compression of neurovascular structures.
Compartment syndrome can happen in any muscle compartment
but it is most common in the lower leg which is where our patient is injured
and this schematic shows the various compartments of the lower leg.
So the signs and symptoms of the patient presents with
should generally identify the affected compartment.
In our case, we’re concerned about the anterior compartment
which is gonna be associated with sensory loss in the first and second webspace,
motor weakness of toe extension so your patient’s not gonna be able to extend the toes
or dorsiflex the foot and also pain on passive stretch when you flex the toes for the patient.
The definitive diagnosis is made with compartment pressures
which can be measure invasively and the treatment is emergent fasciotomy.
This is a really big deal because the only way that you’re gonna alleviate pressure
on the neurovascular structures and restore normal perfusion
is by opening up the compartment and allowing the pressure to be alleviated.
It’s also very important not to wait until the patient loses their pulses
because loss of pulse is a late finding in compartment syndrome.
You really wanna make this diagnosis before the situation gets to that point.
So in summary, I just wanna emphasize the key parts principles for extremity injuries.
History and physical is really, really critical for predicting diagnosis for your patient.
You always wanna do a careful neurovascular assessment and document your findings.
Anytime you have a suspected fracture but your x-ray is negative,
just proceed as though there’s a fracture.
It’s always better safe than sorry.
Always ensure that your patient is safe to ambulate and perform their daily activities
before you discharge them and make sure you anticipate complications,
educate the patient about them
and be prepared to deal with them if the patient comes back to the ED.