# Six hours after closed reduction of a tibial fracture and application of a circumferential long-leg cast, a client reports rapidly worsening deep leg pain that is not relieved by two doses of IV morphine. Pain increases sharply when the nurse passively extends the great toe. The exposed foot is swollen and tense, and the client reports new tingling between the first and second toes. Pedal pulses are palpable, capillary refill is 2 seconds, and the toes are warm. The client has no history of clotting disorders. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617364&lang=en  
> language: en  
> subject: Potential for Alterations in Body Systems  
> category: ROR

## Question

Six hours after closed reduction of a tibial fracture and application of a circumferential long-leg cast, a client reports rapidly worsening deep leg pain that is not relieved by two doses of IV morphine. Pain increases sharply when the nurse passively extends the great toe. The exposed foot is swollen and tense, and the client reports new tingling between the first and second toes. Pedal pulses are palpable, capillary refill is 2 seconds, and the toes are warm. The client has no history of clotting disorders. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Deep vein thrombosis
Acute compartment syndrome
Expected post-reduction swelling
Acute arterial occlusion

Actions to take

Select 2
Elevate the leg on pillows above heart level
Give an extra prescribed opioid dose and recheck in 1 hour
Notify the orthopedic surgeon immediately
Prepare for a prescribed heparin infusion
Prepare to bivalve the cast per protocol

Parameters to monitor

Select 2
Dorsalis pedis pulse strength
Calf circumference measurement
Pain with passive toe stretch
Serum D-dimer level
First web space sensation

## Explanation

Pain out of proportion to the injury that increases with passive stretch, a tense limb, and new paresthesia under a circumferential cast indicate acute compartment syndrome; palpable pulses do not rule it out. The nurse notifies the surgeon immediately and prepares to bivalve the cast. Pain with passive stretch and first-web-space sensation are the most sensitive parameters to trend.

## In-depth explanation

Quick answer
Acute compartment syndrome; notify the orthopedic surgeon immediately and prepare to bivalve the cast; monitor pain with passive toe stretch and sensation in the first web space.

Why this is correct
Compartment pressure rises inside the fascia long before it can stop arterial flow, so pulses and capillary refill stay normal while muscle and nerve become ischemic. Pain that opioids do not control and that spikes with passive stretch is the earliest sign, and tingling in the first web space shows deep peroneal nerve compromise in the anterior compartment. Releasing the cast lowers external pressure while the surgeon evaluates for fasciotomy.

Easy analogy or mental picture
The compartment is a closed suitcase being overpacked: the zipper (fascia) will not stretch, so the soft items inside (nerves, muscle) get crushed before the handle (pulse) is affected.

Memory hook
Pulses are the LAST to go — trust Pain and Paresthesia first.

NCLEX decision rule
Pain out of proportion that worsens with passive stretch after casting is compartment syndrome until proven otherwise; relieve external constriction and notify the surgeon, and never wait for pulse loss.

Why the other choices are wrong
Expected swelling improves with elevation and analgesia and does not cause stretch pain or paresthesia. DVT causes calf pain and swelling but not severe passive-stretch pain or nerve deficits within 6 hours, so heparin, calf circumference, and D-dimer track the wrong condition. Arterial occlusion causes a cold, pulseless foot, but pulses and warmth are preserved here. Elevating above the heart is common for edema, but it lowers arterial inflow to an ischemic compartment; the limb belongs at heart level. An extra opioid masks the key symptom and delays decompression. Pedal pulse strength is tempting but is a late sign.

References
1AAOS — Appropriate Use Criteria: Acute Compartment SyndromeClinical diagnosis of compartment syndrome and urgent decompression
2NCSBN 2026 NCLEX-RN Test PlanClient Needs category and clinical judgment framework

## Clinical scenario

Scenario
Six hours after tibial reduction and casting, pain out of proportion that worsens with passive stretch and new paresthesia develop despite palpable pulses.

## Key concepts

- **Acute compartment syndrome** — Rising pressure within a fascial compartment that compromises nerve and muscle perfusion.
- **Passive stretch pain** — Pain produced by passively stretching muscles in the affected compartment, an early sign.
- **Bivalving** — Splitting a cast along both sides to relieve circumferential pressure.

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