What is the most appropriate initial management for a patient with a compound fracture of the tibia and fibula, signs of compartment syndrome, and a suspected high ankle (syndesmotic) sprain in another patient?

Management of Compound Tibial/Fibular Fracture with Compartment Syndrome

The most appropriate first intervention is immediate fasciotomy of all involved compartments (Option A: Reduction of fracture with surgical consult), as this patient has established compartment syndrome with compartment pressures of 40 mmHg, absent pulses, and loss of sensation—all indicating urgent need for surgical decompression before irreversible tissue damage occurs. 1, 2

Critical Clinical Findings in This Case

This patient presents with multiple indicators of established acute compartment syndrome:

• Compartment pressure of 40 mmHg exceeds the diagnostic threshold of 30 mmHg and indicates immediate need for fasciotomy 3, 4
• Absent pulses and loss of sensation are late signs indicating significant tissue damage has already begun 1, 2
• 4+ pitting edema with discoloration reflects severe tissue ischemia and reperfusion injury 3
• Compound fracture creates dual urgency: both compartment syndrome and open fracture management 3

Why Immediate Fasciotomy Takes Priority

Fasciotomy must be performed before definitive fracture fixation because:

• Compartment syndrome represents a surgical emergency where delays of even hours can result in irreversible muscle necrosis, nerve damage, and potential amputation 1, 2, 5
• The American College of Cardiology explicitly recommends immediate fasciotomy of all involved compartments when compartment syndrome is diagnosed 3, 1, 4
• With compartment pressures ≥30 mmHg combined with clinical signs, fasciotomy should be performed urgently 3
• Late signs (pulselessness, sensory loss) indicate tissue damage is already progressing and cannot be delayed 1, 2

Optimal Surgical Sequence

The correct approach involves:

• Immediate fasciotomy first to decompress all four compartments of the lower leg 1, 2, 4
• Concurrent or immediate subsequent fracture stabilization with internal fixation rather than casting 6, 7
• Administration of antibiotics and tetanus prophylaxis (Option D) should occur perioperatively but does not take priority over fasciotomy 3

Research demonstrates that patients with tibial fractures complicated by compartment syndrome have better anatomic and functional outcomes when treated with fasciotomy followed by stable internal fixation rather than cast immobilization 6, 7.

Why Other Options Are Incorrect

• Option B (Casting) is absolutely contraindicated—any constricting dressings or casts must be removed immediately when compartment syndrome is suspected, and casting would worsen the compartment syndrome 2
• Option C (DVT ultrasound) addresses the wrong diagnosis entirely and would represent a dangerous delay in treating a surgical emergency 3
• Option D (Antibiotics/tetanus) is necessary for the open fracture but does not address the immediate life-and-limb threatening compartment syndrome 3

Post-Fasciotomy Management

After fasciotomy:

• Monitor for myoglobinuria and maintain urine output >2 mL/kg/h to prevent acute kidney injury from rhabdomyolysis 3, 4
• Elevated CPK levels (particularly >75,000 IU/L) indicate high risk of acute kidney injury 3, 4
• Consider early delayed primary closure if minimal tissue bulge occurs with diuresis and elevation 3, 2
• Negative pressure wound therapy facilitates closure when delayed primary closure is not possible 3, 2, 4

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High Ankle (Syndesmotic) Sprain Diagnosis

The squeeze test (Option A) is the most appropriate test to confirm high ankle (syndesmotic) sprain. 3

Rationale for Squeeze Test

• The squeeze test specifically evaluates syndesmotic integrity by compressing the tibia and fibula together at mid-calf, which stresses the syndesmotic ligaments and reproduces pain at the ankle if disrupted 3
• This test has high specificity for syndesmotic injury when combined with appropriate clinical findings 3

Why Other Tests Are Less Appropriate

• Option B (Talar tilt test) evaluates lateral collateral ligament integrity, not syndesmotic injury 3
• Option C (Anterior drawer test) assesses anterior talofibular ligament integrity for lateral ankle sprains, not syndesmotic injury 3
• Option D (Hawkins test) is used for impingement syndrome, not ankle ligament injuries 3

Additional Diagnostic Considerations

• Gravity stress radiographs are more reliable than manual stress views for evaluating syndesmotic injuries with suspected deltoid ligament disruption 3
• High ankle sprains are frequently underdiagnosed and may require additional imaging if clinical suspicion remains high despite negative initial radiographs 3, 8
• Patients with swelling inferior to the lateral malleolus after appropriate mechanism should be carefully evaluated to exclude syndesmotic injury 3