Immediate Fasciotomy is Required
This patient has developed acute compartment syndrome following femoral artery surgery and requires emergency fasciotomy immediately—this is the only intervention that can prevent irreversible muscle necrosis, limb loss, and potentially life-threatening complications. 1, 2, 3
Clinical Recognition
This presentation is classic for post-revascularization compartment syndrome:
- Limb swelling and worsening neurological signs at 6 hours post-surgery are diagnostic hallmarks of acute compartment syndrome 1
- The American College of Cardiology explicitly states that patients with acute limb ischemia must be monitored and treated with fasciotomy for compartment syndrome after revascularization 1
- Reperfusion to ischemic muscles causes cellular edema, resulting in increased compartment pressure that compresses capillaries and venules, leading to muscle malperfusion 1
Why Fasciotomy is the Only Correct Answer
Fasciotomy is indicated when compartment pressure exceeds 30 mmHg, but more importantly, clinical signs alone (increased pain, tense muscle, neurological deficits) mandate immediate intervention without waiting for pressure measurements 1, 2, 3
The other options are completely inappropriate:
- Backslap: Not a recognized medical intervention for this condition
- Traction: Has no role in compartment syndrome management and would delay definitive treatment
- Nerve repair: This addresses a consequence of untreated compartment syndrome, not the underlying problem; attempting nerve repair without decompression would be futile as ongoing ischemia would continue damaging the nerve 2, 3
Surgical Technique Required
Two-incision, four-compartment fasciotomy is the standard approach for lower leg compartment syndrome 2, 4:
- All four compartments (anterior, lateral, superficial posterior, deep posterior) must be decompressed 2, 3, 4
- Fasciotomy wounds must be left open initially due to postoperative swelling risk 2, 5
- Delayed primary closure can be attempted at approximately 5 days if tissue swelling resolves 2
Critical Time-Sensitive Nature
Decompressive fasciotomy before development of ischemic myoneural deficits prevents the ischemic sequelae of acute compartment syndrome 6:
- Irreversible tissue damage occurs within 6 hours of established compartment syndrome 3
- Early fasciotomy (performed before myoneural deficits develop) results in only 7% postoperative myoneural deficits 6
- Delayed fasciotomy leads to permanent muscle necrosis, nerve damage, and potential limb loss 2, 3, 7
Post-Fasciotomy Monitoring
After fasciotomy, monitor for:
- Rhabdomyolysis with elevated CPK levels and myoglobinuria—maintain urine output >2 mL/kg/h to prevent acute kidney injury 2, 3
- CPK levels >75,000 IU/L are associated with >80% incidence of acute kidney injury 3
- Wound infection, which occurred in approximately 9% of cases in one series 8
Common Pitfall to Avoid
Never delay fasciotomy for pressure measurements when clinical signs are present—late signs like pulselessness and sensory loss indicate tissue damage is already progressing 2, 3. The American College of Cardiology emphasizes that evaluation for fasciotomy is prompted by development of increased pain, tense muscle, or nerve injury even when intracompartmental pressure monitoring is not accessible 1.