07-21-2008, 05:42 PM
I found it very interesting.
17. You are called to see a 45-year-old man who is having severe pain 24 hours after an open reduction internal fixation by the orthopaedic surgery service. The nurse states that "no matter what I give him he still complains of excruciating pain". The patient is a laborer who sustained a transverse mid-shaft right tibia fracture. The fracture resulted from a fall from a 10-foot roof in the last 24 hours. He has received oral and intramuscular narcotic analgesics with minimal pain relief. He has a history of hypercholesterolemia, alcohol abuse, peptic ulcer disease, gout, and chronic hepatitis. He takes a daily cholesterol-lowering agent and smokes 2 packs of cigarettes per day. He denies any use of illicit drugs. Physical examination reveals the patient to be afebrile, mildly tachycardic, with otherwise stable vital signs. The right leg is elevated on 2 pillows, and has a splint that is clean, dry, and intact. The patient can wiggle his lesser toes without any increase in pain. All toes are warm with a capillary refill of less than 2 seconds. However, the capillary refill examination of the great toe causes the patient to scream in pain. When asked where the pain is coming from, the patient points to his right leg and states "down there doc, by the cast". You loosen the splint and inspect the surgical dressing that is clean and dry. The surrounding skin is intact, soft, and minimally tender. Unimpressed by the physical examination you decide to observe the patient further. The ward nurse calls you 6 hours later to report that the patient has not improved despite the splint being loosened. At this time the most correct statement about his condition is:
A. He should be made nil per os (NPO) and the chief orthopaedic resident should be contacted. You should inform the chief that this patient has the signs and symptoms of a compartment syndrome. Continue preoperative planning for an emergent right lower extremity fasciotomy.
B. The initial loosening of the splint was inadequate. All circumferential components of the splint and dressing must be cut open. Using scissors you should cut a longitudinal opening in the anterior aspect of the splint and dressing and reflect each side of the dressing, loosening it more than it was previously, and elevating the leg to the level of the heart. You should continue serial physical examinations and measure compartment pressures if indicated.
C. The medical history is suggestive for narcotic tolerance. He should be transferred to a monitored setting, (a step-down unit for example), and increase the narcotic dose and frequency. Consider starting this patient on a controlled analgesic (PCA) pump.
D. The patient is having an acute exacerbation of his gout. Continue his current narcotics, give a stat dose of indomethacin, and add indomethacin to his daily medications.
E. The physical exam is inconclusive for compartment syndrome. You should measure the compartment pressures directly with the standard equipment and if the pressures are elevated then proceed with emergent planning of fasciotomy.
17. You are called to see a 45-year-old man who is having severe pain 24 hours after an open reduction internal fixation by the orthopaedic surgery service. The nurse states that "no matter what I give him he still complains of excruciating pain". The patient is a laborer who sustained a transverse mid-shaft right tibia fracture. The fracture resulted from a fall from a 10-foot roof in the last 24 hours. He has received oral and intramuscular narcotic analgesics with minimal pain relief. He has a history of hypercholesterolemia, alcohol abuse, peptic ulcer disease, gout, and chronic hepatitis. He takes a daily cholesterol-lowering agent and smokes 2 packs of cigarettes per day. He denies any use of illicit drugs. Physical examination reveals the patient to be afebrile, mildly tachycardic, with otherwise stable vital signs. The right leg is elevated on 2 pillows, and has a splint that is clean, dry, and intact. The patient can wiggle his lesser toes without any increase in pain. All toes are warm with a capillary refill of less than 2 seconds. However, the capillary refill examination of the great toe causes the patient to scream in pain. When asked where the pain is coming from, the patient points to his right leg and states "down there doc, by the cast". You loosen the splint and inspect the surgical dressing that is clean and dry. The surrounding skin is intact, soft, and minimally tender. Unimpressed by the physical examination you decide to observe the patient further. The ward nurse calls you 6 hours later to report that the patient has not improved despite the splint being loosened. At this time the most correct statement about his condition is:
A. He should be made nil per os (NPO) and the chief orthopaedic resident should be contacted. You should inform the chief that this patient has the signs and symptoms of a compartment syndrome. Continue preoperative planning for an emergent right lower extremity fasciotomy.
B. The initial loosening of the splint was inadequate. All circumferential components of the splint and dressing must be cut open. Using scissors you should cut a longitudinal opening in the anterior aspect of the splint and dressing and reflect each side of the dressing, loosening it more than it was previously, and elevating the leg to the level of the heart. You should continue serial physical examinations and measure compartment pressures if indicated.
C. The medical history is suggestive for narcotic tolerance. He should be transferred to a monitored setting, (a step-down unit for example), and increase the narcotic dose and frequency. Consider starting this patient on a controlled analgesic (PCA) pump.
D. The patient is having an acute exacerbation of his gout. Continue his current narcotics, give a stat dose of indomethacin, and add indomethacin to his daily medications.
E. The physical exam is inconclusive for compartment syndrome. You should measure the compartment pressures directly with the standard equipment and if the pressures are elevated then proceed with emergent planning of fasciotomy.