Immediate Fasciotomy is Required
This patient has impending compartment syndrome and requires emergency fasciotomy—elevation alone is contraindicated and will worsen the outcome. 1
Clinical Presentation Analysis
The combination of paresthesia and severe pain despite intact distal pulses in a radial fracture represents the classic early warning signs of compartment syndrome, specifically the "four P's": pain, pain with passive stretch, paresthesia, and paresis. 1 Critically, pulselessness and pallor are late signs that indicate irreversible tissue damage has already occurred—their absence does NOT rule out compartment syndrome. 1
Why Fasciotomy (Option A) is Correct
• Early fasciotomy is the definitive treatment for established compartment syndrome and must be performed urgently to prevent permanent neurovascular damage, muscle necrosis, and potential limb loss. 1
• The procedure involves wide incision of skin, subcutaneous tissue, and fascia to decompress all affected compartments. 1
• Timing is critical: Delay beyond 6-8 hours significantly increases the risk of irreversible muscle and nerve damage, leading to permanent disability. 1
• In severe limb trauma with compartment syndrome risk factors (fracture, pain, paresthesia), clinical signs should be investigated repetitively every 30 minutes to 1 hour during the first 24 hours. 1
Why Elevation (Option B) is Wrong and Dangerous
• Elevating the limb above heart level is contraindicated in compartment syndrome because it decreases arterial perfusion pressure to an already compromised compartment, worsening ischemia. 1
• While elevation is appropriate for simple edema management in uncomplicated fractures, it has no role once compartment syndrome is suspected or established. 1
• The differential pressure (diastolic blood pressure minus compartment pressure) becomes critically low with elevation, accelerating tissue death. 1
Diagnostic Confirmation (If Time Permits)
• Compartment pressure measurement >30 mmHg or differential pressure (diastolic BP - compartment pressure) <30 mmHg confirms the diagnosis. 1
• However, clinical diagnosis alone (severe pain and paresthesia) is sufficient to proceed to fasciotomy—do not delay surgery waiting for pressure measurements if clinical suspicion is high. 1
• These clinical signs have low sensitivity but high negative predictive value, meaning their presence mandates immediate action. 1
Common Pitfalls to Avoid
• Do not wait for loss of pulses—by the time pulses disappear, irreversible damage has occurred and the limb may not be salvageable. 1
• Do not rely solely on pain control with analgesics, as this masks the warning signs and delays definitive treatment. 1
• Sedation or altered consciousness can obscure clinical signs, making compartment pressure monitoring more important in these patients. 1
• After fasciotomy, the wound is typically left open initially and requires delayed closure or skin grafting once swelling resolves. 1
Post-Fasciotomy Management
• Aggressive fluid resuscitation is required if rhabdomyolysis develops (CPK >1000 IU/L), with volumes of 3-6L daily for moderate cases and >6L for severe cases (CPK >15,000 IU/L). 1
• Monitor for acute kidney injury from myoglobin release, checking plasma creatinine and potassium levels. 1
• The fracture itself should be stabilized, but definitive osteosynthesis may need to be delayed until soft tissue swelling resolves and compartment syndrome is fully treated. 1