Hip Dislocation - Answers from Tintinalli's and Rosen's Emergency Medicine

Question 1(a): Classification and Clinical Features of Hip Dislocation (5 Marks)

Classification

• Most common type, accounting for 80-90% of all hip dislocations (Rosen's) / >90% (Tintinalli's)
• Results from high-energy trauma - classically a "dashboard injury" where a seated occupant's knee strikes the dashboard, transmitting force through the femoral shaft posteriorly
• The femoral head is forced out through a posterior capsular tear
• May be associated with acetabular rim fractures (fracture-dislocation)

• Accounts for 10-15% of dislocations
• Results from forceful extension, abduction, and external rotation, levering the femoral head out anteriorly
• Further subdivided into:
  • Superior (Pubic/Iliac) type - hip is in extension and mild abduction at time of injury; femoral head lies near the pubis or iliac crest
  • Inferior (Obturator) type - hip is in flexion and abduction; femoral head lies near the obturator foramen
• Associated with femoral artery or femoral nerve injury (less common than sciatic nerve injury in posterior dislocations)

• Accounts for 2-4% of cases
• Not a true dislocation - the entire femoral head is forced centrally through a comminuted fracture of the acetabulum
• High-energy axial load injury

• Very rare
• Occurs with or without associated trochanteric fracture
• Involves inversion of the femoral shaft

Rosen's Emergency Medicine, p.699-700

Clinical Features

Posterior Dislocation:

• Extremity is shortened, adducted, and internally rotated - this is the classic triad
• The knee of the affected limb rests on the opposite thigh
• The greater trochanter and buttock may be unusually prominent
• Differentiating feature from femoral neck fracture: femoral neck fractures present with external rotation, whereas posterior dislocation presents with internal rotation
• Sciatic nerve injury is present in approximately 10% of cases - must carefully assess motor and sensory function in the sciatic distribution (dorsiflexion, eversion, plantar sensation)
• Palpable femoral head posteriorly on the buttock

Anterior Dislocation:

• Extremity is in abduction and external rotation (opposite of posterior dislocation)
• Superior type: hip extended, extremity in external rotation
• Inferior type: hip and knee flexed, thigh held in extreme abduction - appears as if the extremity is pointing toward the ceiling
• Femoral artery and femoral nerve at risk - check femoral pulse and sensation of anterior thigh/medial leg

General Features (All Types):

• Severe hip pain with inability to bear weight
• Limb deformity and shortening (except in some anterior types)
• History of high-energy trauma (MVC is most common mechanism)
• Up to 95% of patients with native hip dislocations have other associated injuries (Tintinalli's)
• Up to 30% have associated knee ligamentous injuries or fractures (Rosen's)
• Up to 50% of children have fractures elsewhere (Rosen's)

Radiological Features:

• AP and lateral pelvis X-ray: posterior dislocation shows loss of the lesser trochanter on AP view; the femoral head appears smaller (farther from detector) and above/posterior to the acetabulum
• Disruption of Shenton's line (smooth curved line along the superior border of obturator foramen and medial femoral metaphysis) suggests dislocation or femoral neck fracture
• CT scan is mandatory after identification to evaluate acetabulum and femoral head for associated fractures

Tintinalli's Emergency Medicine, p.1887-1890; Rosen's Emergency Medicine, p.699-701

Question 1(b): Reduction Techniques in Posterior Hip Dislocation (5 Marks)

• Rule out ipsilateral femoral neck fracture on X-ray (traction maneuvers in femoral neck fracture can cause displacement)
• IV procedural sedation and analgesia
• Pelvic stabilization with an assistant
• Multiple attempts should be avoided if unsuccessful - early orthopaedic consultation required

Technique 1: Allis Maneuver (Most Common)

1. Place the patient supine on a backboard on the floor (preferred over standing on a stretcher - reduces clinician back injury risk per Rosen's)
2. Secure the pelvis to the stretcher with a sheet or strap over the ischial wings and pubic symphysis - an assistant stabilizes the pelvis by applying downward pressure on the anterior superior iliac spines (ASIS)
3. Stand astride the patient or beside the bed (if patient is on stretcher)
4. Flex the patient's hip and knee to 90 degrees
5. Apply steady in-line traction upward toward the ceiling (in the direction of the deformity), then slightly toward the contralateral side - this achieves the required flexion and adduction
6. Apply gentle internal rotation if needed while under traction
7. The assistant may push the greater trochanter forward toward the acetabulum
8. Once reduction is achieved (felt as a "clunk"), bring the hip to the extended position while maintaining traction

Tintinalli's, p.1888; Rosen's, p.700, Fig. 47.25

Technique 2: Stimson (Gravity) Technique

1. Place the patient prone (face down) on the stretcher
2. The affected leg hangs over the edge of the bed, with hip and knee flexed at 90 degrees
3. An assistant stabilizes the pelvis against the stretcher
4. The physician applies gentle downward pressure on the popliteal fossa (behind the knee) - this leverages the femoral head anteriorly back into the acetabulum
5. Gentle rotation of the leg may assist reduction

Rosen's Emergency Medicine, p.701, Fig. 47.26

Technique 3: Bigelow Maneuver

1. Patient is supine, hip and knee flexed to 90 degrees
2. The physician secures the patient's knee with the flexed elbow, and grasps the patient's foot with the opposite hand
3. An assistant applies downward pressure on the ASIS to stabilize the pelvis
4. Using the flexed elbow under the knee, lift upward (apply traction to the femur at the knee)
5. While applying traction, gently externally rotate and extend the hip
6. Reduction is confirmed by a palpable/audible clunk

Tintinalli's Emergency Medicine, p.1888, Fig. 273-9

Technique 4: Captain Morgan Technique

1. Patient is supine on the stretcher in its lowest position
2. Secure the pelvis to the stretcher with a sheet or strap
3. The physician places their knee under the patient's popliteal fossa (physician's knee acts as a fulcrum)
4. Flex both the patient's hip and knee to 90 degrees by resting the leg on the physician's thigh
5. The physician then plantar-flexes their own foot, raising the heel - this elevates the patient's leg, applying upward traction through the femur
6. Simultaneous gentle internal and external rotation of the limb assists reduction

Tintinalli's, p.1888, Fig. 273-11; Rosen's, p.701, Fig. 47.27

Technique 5: Whistler Technique

1. Patient is supine
2. The physician flexes the patient's knee and slides their arm under the popliteal fossa
3. The physician's hand grasps the patient's wrist of the same side
4. Upward traction is then applied by lifting through the arm - the physician's forearm acts as a lever under the knee
5. Gentle rotation aids reduction

Rosen's Emergency Medicine, p.701, Fig. 47.28

Post-Reduction Care

• Immediately reassess neurovascular status (sciatic nerve function)
• Gently range the hip
• Confirm reduction with post-reduction imaging (X-ray and CT)
• Immobilization: Abduction pillow (extension + abduction position prevents re-dislocation since flexion + adduction cause it) OR knee immobilizer
• Most patients require hospital admission due to associated injuries from high-energy trauma
• Orthopedic consultation required if:
  • Reduction unsuccessful after several attempts
  • Irreducible fracture
  • Complex fracture-dislocation

Tintinalli's Emergency Medicine, p.1889; Rosen's Emergency Medicine, p.701

Emergency Medicine Exam Answers - Tintinalli's & Rosen's

Question (a): Emergency Management of Pelvic Fracture (3 Marks)

Overview

Tintinalli's, p.1882; Rosen's, p.698

1. Initial Resuscitation (ABCs)

• Airway and Breathing: Secure airway; supplemental oxygen
• Circulation: Establish two large-bore IV lines (14-16G) in the upper limbs - IV access in the lower limbs must be avoided in severe pelvic fractures, as fluids may be lost through venous bleeding into the retroperitoneal space (Rosen's)
• Intraosseous access is suitable when peripheral IV is difficult
• Begin resuscitation with crystalloid in 250-500 mL aliquots, assessing response; transition early to blood products if ongoing hemorrhage is suspected
• Do NOT aim for normal blood pressure with fluids alone in the ED - this may worsen bleeding and delay definitive treatment (Rosen's)
• Continuous monitoring: ECG, pulse oximetry, BP, mental status, end-tidal CO2

2. Mechanical Stabilization of the Pelvis

• Pelvic binder / Sheet and towel clamps: Wrap a folded bed sheet tightly around the pelvis at the level of the greater trochanters and secure with towel clips. This reduces pelvic volume, decreases retroperitoneal space, and tamponades venous bleeding.
  • Most effective for open-book (anteroposterior compression) fractures
  • Caution: Lateral compression fractures already have internal rotation - further compression may worsen displacement. Do NOT apply binder blindly to all pelvic fractures.
  • Associated with improved survival and lower mean blood transfusion volumes (Rosen's)
• Commercial circumferential compression devices (e.g., T-POD, SAM Pelvic Sling) are equally effective cadaveric alternatives
• Formal external fixation: Performed by orthopedic surgeons in the OR; prevents movement at fracture sites but is less effective than angiography for arterial hemorrhage

3. Imaging and Evaluation

• FAST exam: Performed at bedside; detects intraperitoneal free fluid. However, FAST false-positive rate for intraperitoneal hemorrhage in pelvic fractures is up to 30% (Tintinalli's). A negative FAST does not exclude significant injury.
• CT thoracoabdominopelvic scan with IV contrast: Investigation of choice. Identifies intra-abdominal and retroperitoneal bleeding. Contrast blush on CT indicates active arterial hemorrhage requiring angiography.
• Pelvic CTA: More accurately localizes active pelvic bleeding and distinguishes arterial from venous sources (Rosen's)
• DPL (Diagnostic Peritoneal Lavage): Now largely supplanted by FAST and CT; used only when CT unavailable

• Initial haematocrit <30%
• Pelvic haematoma on CT
• Systolic BP <90 mmHg on arrival
• Base deficit <6 mmol/L or worsening base deficit >2 mmol/L in the ED

4. Hemorrhage Control Interventions

• Most effective modality for arterial pelvic hemorrhage
• Takes precedence over external fixation for arterial bleeding (Rosen's)
• Used when contrast blush on CT confirms active arterial extravasation
• Delay to angioembolization directly increases mortality

• Surgical packing of the retroperitoneal space via a midline incision
• Highly effective for venous bleeding (which accounts for the majority of pelvic hemorrhage)
• Used when angiography is unavailable or when rapid OR control is needed
• Can be performed concurrently or sequentially with external fixation

• Catheter-based aortic balloon inflation to provide temporary hemorrhage control in exsanguinating patients
• Bridge to definitive surgical/angiographic management

• Anti-fibrinolytic agent; CRASH-2 trial demonstrated significant reduction in deaths from traumatic hemorrhage
• Administer within 3 hours of injury (benefit is lost after 3 hours)

ED Goals Summary (Rosen's Box 46.9):

1. Resuscitate: Recognize hemorrhagic shock and initiate blood transfusion early
2. Recognize: Posterior arch injuries carry the highest risk of hemorrhage
3. Evaluate: Search for non-pelvic injuries (head, chest, abdomen)
4. Stabilize: Sheet/towel clamps or pelvic binder immediately
5. Control: Angiography for arterial bleeding; packing for venous bleeding
6. Prevent: Avoid hypothermia; maintain temperature above 36°C

Tintinalli's Emergency Medicine, p.1881-1884; Rosen's Emergency Medicine, p.697-701

Question (b): Principles of Damage Control Resuscitation (DCR) (3 Marks)

Definition

Core Principles of DCR

1. Permissive (Hemostatic) Hypotension

• Do NOT normalize blood pressure with aggressive fluid resuscitation before surgical hemorrhage control
• Raising blood pressure in the presence of non-compressible bleeding can "pop the clot" and re-establish active hemorrhage
• Acceptable target SBP:
  • ~90 mmHg is the commonly used target in civilian trauma (Tintinalli's)
  • 110 mmHg is the threshold below which adverse outcomes increase in civilian trauma (Tintinalli's)
  • ~100 mmHg in combat casualties
• Contraindicated in patients with traumatic brain injury (TBI), myocardial disease, or cerebral ischemia - these require a higher perfusion pressure to prevent secondary brain injury

2. Hemostatic Resuscitation (Blood Product-Based Resuscitation)

• Replace lost blood with blood products in balanced ratios - not crystalloid
• Avoid large volumes of crystalloid (causes coagulopathy, hypothermia, and dilutional anaemia)
• Target a 1:1:1 ratio of Packed Red Blood Cells (PRBCs) : Fresh Frozen Plasma (FFP) : Platelets
  • Based on combat casualty data showing significantly improved survival with high plasma:PRBC ratios
  • Plasma provides coagulation factors, endothelial repair, and reduces vascular permeability
  • The PROPPR trial (multicenter RCT) compared 1:1:1 vs 2:1:1 and found fewer deaths from exsanguination at 24 hours in the 1:1:1 group (Rosen's)
• Early activation of Massive Transfusion Protocol (MTP)

3. Prevention and Correction of the Lethal Triad

• Hypothermia: Causes platelet dysfunction and reduces clotting factor activity. Prevent with warmed IV fluids, blood warmers, warming blankets/lights. Maintain temperature >36°C.
• Acidosis: Results from tissue hypoperfusion. Corrected by restoring adequate perfusion via hemorrhage control and balanced resuscitation. Avoid large volumes of normal saline (causes hyperchloremic acidosis).
• Coagulopathy (Acute Traumatic Coagulopathy / ATC): Early coagulopathy in trauma is now recognized as an independent process. Correct with FFP, cryoprecipitate (fibrinogen), and platelets.

4. Limit Crystalloid Use

• Crystalloid solutions are hypo-oncotic and shift to the extravascular space - only ~30% remains intravascular
• Large volumes worsen coagulopathy (dilutional), hypothermia, and the lethal triad
• Use crystalloid only as a bridge in small aliquots (250-500 mL) while awaiting blood products

5. Adjuncts

• Tranexamic Acid (TXA): Anti-fibrinolytic; reduces mortality in bleeding trauma patients (CRASH-2 trial). Give within 3 hours.
• Calcium: Maintain ionized calcium ≥0.9 mmol/L; calcium is consumed during massive transfusion and is critical for clot formation
• Cryoprecipitate / Fibrinogen concentrate: Replenishes fibrinogen when levels fall below 1.5 g/L

6. Damage Control Surgery

• DCR is paired with Damage Control Surgery (DCS): temporizing surgical procedures to control life-threatening hemorrhage and contamination, with delayed definitive repair after physiologic normalization in the ICU

Tintinalli's Emergency Medicine, p.107-109; Rosen's Emergency Medicine, p.698-701

Question (c): Massive Transfusion Protocol (MTP) (4 Marks)

Definition

Massive transfusion is not a substitute for definitive surgical hemostasis but enhances the ability to achieve it.

Prediction / Activation of MTP

• Score ≥2 indicates likely need for MTP (sensitivity 76-90%, specificity 67-87%)
• If hemorrhage is significant and immediate hemostasis is not achievable: transition from crystalloid-based to plasma-based MTP

Blood Products in MTP

1. Packed Red Blood Cells (PRBCs)

• Restores oxygen-carrying capacity
• Stored up to 45 days; however storage >21 days may cause "storage lesion" (loss of deformability, altered O2 dissociation curve from 2,3-DPG loss)
• Order preference: Type and cross-matched > Type-specific > O-negative (universal donor) for emergencies
• Transfusion threshold: If hemorrhage is controlled, transfuse only if Hb <7 g/dL (no comorbidities); use clinical judgment for Hb <10 g/dL with cardiopulmonary/cerebrovascular disease

2. Fresh Frozen Plasma (FFP)

• Contains all coagulation factors in fresh blood
• Volume: 200-250 mL per unit; stored frozen up to 1 year
• Requires 15-20 minutes to thaw (major trauma centers keep pre-thawed FFP ready)
• ABO compatibility required; Rh compatibility less critical (no red cells)
• Universal donor = AB+ FFP (no crossmatch needed for emergency use)
• Corrects factor deficiencies and provides endothelial repair

3. Platelets

• Stored up to only 5 days
• 6 units of pooled random-donor or 1 apheresis unit raises platelet count by ~50,000/mm³
• Platelet function decreases rapidly after trauma - early inclusion in MTP is supported
• Target platelet count ≥50,000/mm³ (≥100,000 if TBI or multisystem trauma)

4. Cryoprecipitate

• Rich in fibrinogen, Factor VIII, Factor XIII, vWF, and fibronectin
• Indicated when fibrinogen <1.5 g/L (consumed early in massive hemorrhage)
• Given as part of MTP when fibrinogen is critically low

The Ratio Debate: 1:1:1 vs 2:1:1

Adjuncts in MTP

Complications of Massive Transfusion

MTP Activation and Discontinuation

• Activation: When ABC score ≥2, or clinical judgment of ongoing non-compressible hemorrhage requiring >3-4 units blood products; physician or nurse initiated
• MTP packs are released from the blood bank in pre-configured bundles (e.g., 6 PRBCs + 6 FFP + 1 platelet apheresis unit = "pack 1")
• Discontinuation: When hemorrhage is surgically controlled, vital signs stabilize, and ongoing blood loss ceases; confirmed by normalization of lab values (INR, fibrinogen, platelet count, lactate)
• Each institution maintains a specific MTP tailored to their blood bank capacity - Figure 13-4 in Tintinalli's (University of Michigan Level I Trauma Center protocol) illustrates a full institutional MTP flowchart

Tintinalli's Emergency Medicine, p.107-110; Rosen's Emergency Medicine, p.2429-2430

Compartment Syndrome - Answers from Tintinalli's & Rosen's Emergency Medicine

Question (a): Define Compartment Syndrome (2 Marks)

Definition

• Tintinalli's (Ch. 278): "Compartment syndrome occurs when increased pressure within a limited space compromises the circulation and function of the muscles and nerves within that space."
• Rosen's (Ch. 41): "Compartment syndrome is an acute, emergent complication that should be considered whenever significant pain and paresthesias occur in an extremity following a fracture or crush injury within an enclosed osseofascial space."

Pathophysiology (Brief)

• Normal compartment pressure: 0-10 mmHg (Rosen's states 0 mmHg; Tintinalli's states <10 mmHg)
• Pressures up to 20 mmHg can be tolerated without damage
• As content volume increases within the rigid osseofascial compartment → tissue pressure rises → venous pressure rises → local arteriovenous gradient falls → capillary perfusion fails → ischemia of enclosed muscles and nerves
• Histamine released in response dilates capillaries and increases permeability → protein/fluid leak → further pressure rise = a vicious cycle
• Ischemia begins when tissue pressure rises to within 20-30 mmHg of diastolic blood pressure (delta P <30)

Tintinalli's, p.1918; Rosen's, p.540-541

Question (b): Clinical Features and Diagnosis of Compartment Syndrome (4 Marks)

Causes / Precipitating Factors

Clinical Features

The 6 Ps (Classical Mnemonic - with Important Caveats)

Critical teaching point from Rosen's: The "5 Ps" (pain, pallor, pulselessness, paresthesias, paralysis) are not reliable signs of compartment syndrome - they are signs of acute arterial disruption. Skin color, temperature, capillary refill, and distal pulses are all unreliable monitors because the pressure that causes compartment syndrome is well below arterial pressure. Pallor and pulselessness are late and ominous signs. Clinical reliance on these is a common and dangerous error.

1. Pain

• Severe, deep, burning, unrelenting pain disproportionate to the apparent injury - this is the hallmark finding (Rosen's)
• Refractory to opioid analgesia - increasing analgesic requirement should prompt suspicion (Tintinalli's)
• In the awake patient, this is the first symptom, typically developing within a few hours of injury
• Do NOT conclude the patient is "drug-seeking" - escalating pain demands should prompt reassessment for compartment syndrome (Rosen's)

2. Pain on Passive Stretch

• The most sensitive clinical finding before onset of ischemic dysfunction (Tintinalli's)
• Pain is aggravated by passive or active stretching of the muscles within the affected compartment
• Example: passive dorsiflexion of the foot worsens anterior compartment pain in the leg
• Squeezing or palpating the compartment also exacerbates pain

3. Paresthesia / Hypoesthesia

• Numbness, tingling, or dysesthesia in the sensory distribution of the nerve traversing that compartment
• Example: Anterior compartment syndrome → deep peroneal nerve involvement → numbness in the first web space
• Motor nerve function may also be affected - weakness of muscles supplied by the involved nerve

4. Tense / Wooden Compartment

• Firmness or fullness detected on palpation of the affected compartment
• The compartment feels "wooden" or hard (Rosen's uses "tenseness or sensation of tightness")
• This is a reliable suggestive sign (Rosen's)

5. Distal Pulse

• Pulses are typically PRESERVED in compartment syndrome (Tintinalli's)
• Tissue pressures do not rise to arterial levels - the distal pulse remains normal
• Absence of pulse indicates a separate, more severe vascular injury
• This is a critical point that distinguishes compartment syndrome from arterial occlusion

6. Motor Loss / Paralysis

• Late sign - indicates established muscle and nerve ischemia
• Indicates irreversible damage may already be occurring

Special Populations

• Obtunded/unconscious patients: Clinical features cannot be reliably elicited - a high index of suspicion and mandatory pressure measurement is required
• Children: May be unable to articulate pain reliably - the "three As" of agitation, anxiety, and increasing analgesic requirement should raise suspicion

Diagnosis

A. Clinical Diagnosis (Primary)

• Pain out of proportion to injury
• Pain on passive stretch
• Tense compartment on palpation

B. Compartment Pressure Measurement (Confirmatory)

• Clinical diagnosis is unclear
• Patient is unconscious, intoxicated, or uncooperative
• Serial monitoring is needed (e.g., post-fracture fixation)

• Stryker Intra-Compartmental Pressure Monitor: Most widely used commercially available hand-held digital device; easy to use with minimal training (Rosen's). Zero the device at the level of insertion. Insert needle into the relevant compartment; inject a small amount of saline to clear the needle; read pressure in mmHg.
• Slit catheter / Side-port needle technique: Connected to a saline-filled syringe and manometer
• Measure within 5 cm of the fracture site (pressures are highest at the injury level)
• Check adjacent compartments as well
• A single measurement is less reliable than serial or continuous monitoring - a rising or sustained elevated pressure is superior as an indicator (Rosen's)

• The delta pressure (ΔP) threshold is particularly useful in hypotensive patients where absolute pressure thresholds are unreliable (Tintinalli's)
• Continuous monitoring has a sensitivity of 94% and specificity of 98% (Tintinalli's)

Key teaching: A hand-held Doppler is not useful for evaluating compartment syndrome - arterial flow may be detected even in the presence of significant compartment syndrome (Rosen's).

C. Laboratory Tests

• Not diagnostic, but supportive findings include:
  • Elevated serum creatine phosphokinase (CPK) - indicates muscle damage
  • Elevated serum myoglobin
  • Myoglobinuria on urinalysis (urine may appear brown/tea-coloured)
  • Elevated serum lactate - may serve as a clue (Rosen's)
  • Elevated potassium (hyperkalemia from necrotic muscle)
• Coagulation studies in hemophiliacs / patients on anticoagulants

D. Timetable of Irreversible Damage (Tintinalli's Table)

Tintinalli's, p.1919-1920; Rosen's, p.541-543

Question (c): Management of Compartment Syndrome (4 Marks)

Principle

1. Immediate ED Measures (Medical Management)

• Remove all casts, tight dressings, bandages, air splints, and circumferential dressings
• This alone can markedly reduce tissue pressures (Tintinalli's)
• Bivalving a cast has been shown to reduce compartment pressure by ~30-65%

• Place the affected limb at the level of the heart - neither elevated nor dependent
• Do NOT elevate the limb above heart level - this reduces arterial inflow while failing to improve venous outflow, and actually worsens the arteriovenous gradient and exacerbates compartment syndrome (both Tintinalli's and Rosen's - this is a critical point)
• Slight dependency (e.g., reverse Trendelenburg) has been suggested to maximize arterial flow (Rosen's)

• Treat hypotension aggressively - in a hypotensive patient the perfusion pressure to the compartment is reduced, worsening ischemia even at lower compartment pressures
• Administer oxygen; IV access; analgesia (opioids, despite often being insufficient)

• Hemophiliacs: Immediate factor replacement (e.g., Factor VIII)
• Anticoagulated patients: Reversal of anticoagulation or factor replacement

• Aggressive IV fluid resuscitation to maintain urine output ≥1 mL/kg/hr to prevent myoglobin-induced acute kidney injury
• Monitor renal function, potassium, calcium

2. Surgical Management - Fasciotomy (Definitive Treatment)

• Absolute compartment pressure >45 mmHg
• ΔP (Diastolic BP - Compartment Pressure) <30 mmHg
• Clinical signs of compartment syndrome even without pressure measurement in obvious cases
• Early consultation - do not delay for further investigations when diagnosis is clear

• Long incisions are required - adequate length is essential to fully release all compartments
• All involved compartments and adjacent compartments must be released simultaneously
• Muscle will typically bulge from the incision sites due to tissue oedema
• Leave wounds OPEN after fasciotomy - primary closure is contraindicated
• Second-look procedure for debridement within 48-72 hours post-fasciotomy
• Definitive wound closure within 7-10 days, which may require split-thickness skin grafting (Tintinalli's)

• Lower leg: Release all 4 compartments (anterior, lateral, superficial posterior, deep posterior) - typically via 2 incisions (lateral and medial)
• Forearm: Release flexor, extensor, and mobile wad compartments
• Thigh: Release anterior, posterior, and medial compartments
• Hand/Foot: Multiple small compartments; many surgeons proceed to fasciotomy without formal pressure measurement given the small size of compartments (Tintinalli's)

• Missed/delayed diagnosis >24-48 hours: Tissue pressures elevated for this duration may have already caused permanent dysfunction - opening compartments at this stage may be futile and increases risk of infection and sepsis

3. Post-Fasciotomy Care

• Serial monitoring for signs of infection in the open wound
• Regular wound care and dressing changes
• Neurovascular assessment of the limb
• Staged wound closure (primary closure or skin grafting)
• Physiotherapy and rehabilitation for functional recovery

4. Admission and Disposition

• Admit all patients with compartment syndrome for surgical management or appropriate inpatient monitoring (Tintinalli's)
• For patients with equivocal findings who are discharged: strict return precautions for worsening pain, paresthesia, or motor dysfunction, with close outpatient follow-up

Complications of Compartment Syndrome (If Untreated or Late Treatment)

Tintinalli's Emergency Medicine Ch.278, p.1918-1922; Rosen's Emergency Medicine Ch.41, p.540-543