Three weeks after application of a hip spica cast for a femoral fracture, a 28-year-old man develops recurrent postprandial abdominal pain, bloating, and bilious vomiting relieved briefly by vomiting. Abdominal radiograph shows dilated proximal small bowel loops. What is the most appropriate first step in management?

• A Colonoscopic decompression
• B Immediate laparotomy with duodenojejunostomy
• C Conversion of diet to high fibre supplements with prokinetics
• D Splitting or removal of the cast along with nasogastric decompression and intravenous fluids ✓

Explanation

This is cast syndrome: superior mesenteric artery obstruction of the duodenum caused by extrinsic compression between the SMA and the aorta when spinal hyperextension and recumbency in a body or hip spica reduce the aortomesenteric angle. Early treatment is conservative: split or remove the cast, place the patient prone or left lateral, provide nasogastric suction and fluid resuscitation. Surgery such as duodenojejunostomy is reserved for refractory cases. High fibre diets and colonoscopy do not address the duodenal obstruction.

Reference: Miller's Review of Orthopaedics, 8th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.