What is the best course of action for an elderly man, 6 hours post-femoral artery surgery, presenting with swelling and worsening neurological signs?

Immediate Fasciotomy is Required

This elderly patient presenting 6 hours post-femoral artery surgery with swelling and worsening neurological signs has acute compartment syndrome requiring emergency fasciotomy without delay. 1, 2

Clinical Recognition and Urgency

• Worsening neurological signs combined with swelling in the postoperative period are hallmark indicators of compartment syndrome requiring immediate surgical decompression 3, 1
• The 6-hour timeframe is critical—compartment syndrome following vascular surgery can progress rapidly to irreversible muscle necrosis, myoglobinuria, and renal failure if not treated emergently 1, 2
• Intense pain, swelling, and neurological deficits (sensory and motor changes) characterize early presentation and demand immediate intervention 1, 4

Pathophysiology in Post-Femoral Artery Surgery

• Compartment syndrome after femoral artery surgery results from reperfusion injury following acute ischemia, with the anterior thigh muscle group at highest risk due to its layered anatomical arrangement 1
• Femoral arterial cannulation can cause prolonged ischemia, particularly when combined with poor collateral circulation 5
• Concomitant femoral vein injury, femoral nerve injury, and need for blood transfusions are independent risk factors that significantly increase compartment syndrome risk (odds ratios 3.1,3.8, and 2.5 respectively) 2

Immediate Management Algorithm

Step 1: Emergency Fasciotomy

• Perform lateral thigh fasciotomy immediately upon diagnosis—do not delay for additional imaging if clinical diagnosis is clear 1, 2
• 97% of patients with lower extremity compartment syndrome following femoral artery injury require fasciotomy 2
• Timely fasciotomy is both limb-saving and life-saving 1

Step 2: Intraoperative Assessment

• Extensive debridement of any necrotic muscle tissue encountered during fasciotomy 1
• Assess for deep femoral artery rupture or injury, which can be difficult to diagnose due to anatomical location but is life-threatening 6
• Leave wounds open initially for delayed closure after edema resolution 1

Step 3: Monitor for Systemic Complications

• Rhabdomyolysis commonly occurs post-fasciotomy and requires aggressive treatment with electrolyte correction and diuretic therapy 6
• Monitor for myoglobinuria and renal failure 1
• Maintain hemodynamic stability with fluid resuscitation 3

Critical Pitfalls to Avoid

• Never delay fasciotomy to obtain additional imaging studies—clinical diagnosis based on pain, swelling, and neurological deficit is sufficient 1, 2
• Do not underestimate the severity based on preserved distal pulses—compartment syndrome can occur with intact circulation 1
• Avoid attributing neurological symptoms solely to anesthesia or positioning—assume compartment syndrome until proven otherwise in this clinical context 7, 1
• Delaying surgical evacuation leads to prolonged or permanent disability 4

Postoperative Monitoring

• Continue monitoring compartment pressures and neurovascular status after initial fasciotomy 7
• Assess for need for repeat debridement at 24-48 hours 1
• Plan for delayed wound closure or vacuum-assisted closure once edema resolves 6
• Monitor renal function closely for acute kidney injury from myoglobinuria 6, 1

The sequence "backslap - traction - fasciotomy - nerve repair" mentioned in the question is incorrect—fasciotomy must be performed first and immediately, followed by assessment for nerve injury that may require later repair after the acute compartment syndrome is resolved 1, 2.