A 70-year-old man undergoes successful embolectomy for acute limb ischaemia of 14 hours duration. Six hours postoperatively the calf is tense and swollen, pain is disproportionate and worse on passive toe extension, and the dorsalis pedis pulse is palpable. The most appropriate next step is:

• A Urgent four-compartment fasciotomy ✓
• B Increase systemic heparin dose
• C Re-exploration of the femoral embolectomy site
• D Elevation of the limb and ice packs

Explanation

Reperfusion after prolonged ischaemia causes capillary leak and oedema within the fixed fascial compartments, raising interstitial pressure above capillary perfusion pressure. Pain out of proportion, pain on passive stretch, and a tense calf are diagnostic even with a palpable pulse, since the pulse reflects inflow pressure, not tissue perfusion. Treatment is urgent fasciotomy of all four leg compartments; elevation and cooling are harmful, and anticoagulation does not reduce compartment pressure.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.