# A 22-year-old with a tibia fracture in a long leg cast reports increasing pain unrelieved by opioids 8 hours postop, worsened with passive toe extension. The toes are pale and cool. Which action is the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375126&lang=en  
> language: en  
> subject: NCLEX-RN  
> category: PPT

## Question

A 22-year-old with a tibia fracture in a long leg cast reports increasing pain unrelieved by opioids 8 hours postop, worsened with passive toe extension. The toes are pale and cool. Which action is the priority?

## Option

1. Notify provider and prepare for emergent bivalve of cast and fasciotomy **✔ Correct answer**
2. Elevate the leg above heart level to reduce swelling
3. Apply ice packs to the affected limb
4. Increase opioid dosing and reassess in 1 hour

**Correct answer: 1**

## Explanation

Acute compartment syndrome is an orthopedic emergency. The cardinal early sign is pain OUT OF PROPORTION to injury, especially with passive stretch. Late signs (pulselessness, paralysis, pallor) indicate already established ischemic damage. Compartment pressure over 30 mmHg or delta P (DBP - compartment pressure) under 30 mmHg confirms diagnosis. Cast must be bivalved IMMEDIATELY — not delayed. Fasciotomy within 6 hours of symptom onset prevents permanent damage. Elevation ABOVE the heart in established compartment syndrome can WORSEN perfusion (limb at heart level). Ice may decrease perfusion. Increased opioids mask symptoms — never the answer.

## In-depth explanation

5 Ps mnemonic: Pain (early), Paresthesia, Pallor, Paralysis, Pulselessness (late). Pain out of proportion is THE most sensitive early sign.

## Clinical scenario

Compartment pressure 42 mmHg. Diastolic BP 76 (delta P 34).

## Key concepts

- **compartment syndrome** — Increased pressure in fascial compartment compromising tissue perfusion.
- **delta P** — Diastolic BP minus compartment pressure; under 30 mmHg = compartment syndrome.
- **fasciotomy** — Surgical fascial incision relieving compartment pressure; needed within 6 hours.

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