What is the immediate management for a patient with a radial bone fracture, intact distal pulses, paresthesia, and severe pain?

Immediate Management of Radial Fracture with Paresthesia and Severe Pain

This patient requires urgent fasciotomy (Option A) as the combination of severe pain and paresthesia with intact pulses represents impending or early compartment syndrome, which is a surgical emergency. 1

Clinical Recognition of Compartment Syndrome

The presentation described represents the classic early signs of compartment syndrome, which requires immediate surgical intervention:

• Pain and paresthesia are early warning signs that indicate compartment syndrome is developing, even when distal pulses remain intact 1
• The "four P's" (pain, pain with passive stretch, paresthesia, and paresis) are the key diagnostic features 1
• Pulselessness and pallor are late signs that indicate irreversible tissue damage has already occurred—their absence does not rule out compartment syndrome 1
• Waiting for pulse loss before intervening results in irreversible muscle and nerve damage 1

Why Elevation is Contraindicated

Elevating the arm above heart level (Option B) is inappropriate and potentially harmful in this scenario:

• Elevation may further compromise perfusion to an already ischemic compartment 1
• The presence of severe pain and paresthesia indicates that tissue pressure is already critically elevated 1
• Elevation is appropriate for simple fractures without neurovascular compromise, but not when compartment syndrome is suspected 2

Immediate Management Algorithm

Urgent fasciotomy is indicated when:

• Severe pain (especially pain with passive stretch) is present 1
• Paresthesia develops in the setting of limb trauma 1
• Clinical signs suggest compartment syndrome, regardless of pulse status 1

The surgical approach involves:

• Wide incision of skin, subcutaneous tissue, and fascia to decompress all affected compartments 1
• Early fasciotomy (within hours) prevents irreversible muscle necrosis and nerve damage 1
• Delay in treatment leads to permanent disability, including muscle contractures and nerve dysfunction 1

Critical Pitfalls to Avoid

• Do not wait for pulse loss before performing fasciotomy—this represents irreversible damage 1
• Do not rely on compartment pressure measurements alone if clinical signs are present; clinical diagnosis has high negative predictive value 1
• Do not elevate the limb when compartment syndrome is suspected, as this may worsen ischemia 1
• Repetitive clinical examination every 30 minutes to 1 hour during the first 24 hours is essential for patients with fractures and compartment syndrome risk factors 1

Supporting Diagnostic Measures

If there is any diagnostic uncertainty (though clinical signs should drive immediate action):

• Compartment pressure >30 mmHg supports the diagnosis 1
• Differential pressure (diastolic BP minus compartment pressure) <30 mmHg indicates compartment syndrome 1
• However, clinical signs should prompt immediate fasciotomy without waiting for pressure measurements 1