On examination, you note pain with passive stretching, pain with palpation anteriorly, and a slightly decreased dorsalis pedis pulse on the left. There is no oedema or erythema. Radiographs of the lower extremity are normal. Which one of the following would you do now?
a. Recommend rest, ice, and elevation, along with physical therapy
b. Begin empiric intravenous antibiotics
c. Order duplex Doppler ultrasonography of the left leg
d. Order impedance plethysmography of the left leg
e. Obtain immediate surgical consultation
The correct answer is E.
The patient has a history and symptoms very suggestive of a compartment syndrome of the anterior compartment of the left leg. A common cause of this serious problem is limb compression during prolonged recumbency related to drug or alcohol overdose. Early diagnosis and treatment are essential in order to avoid permanent, severe disability.
The five “P’s” of compartment syndrome are pain, pallor, paresthesias, pulselessness, and paralysis. If distal pulses are reduced, then muscle necrosis has occurred and immediate surgical consultation is necessary. Duplex Doppler ultrasonography and impedance plethysmography are used to evaluate for deep venous thrombosis. Given the decreased pulses, however, this diagnosis is much less likely and such testing may needlessly delay urgent surgical treatment. Intravenous antibiotics would be appropriate for cellulitis. This diagnosis is unlikely in this scenario given the absence of fever, erythema, and oedema, and the presence of a diminished pulse. Rest, ice, and elevation are inappropriate treatment modalities for compartment syndrome.