A 25 yo male presents with severe left leg pain after falling over a fence.  On exam, he has an obvious deformity and marked swelling of his left leg.  Distal motor and sensory function are intact.  One hour later, despite IV analgesia he has worsening pain and his affeted extremity is more swollen and tense.  An x-ray is shown.  What's the diagnosis?  Scroll down for answer. 

Answer:  Comminuted tibial plateau (Schatzker Type VI) fracture, fibular fracture and compartment syndrome 

• The tibia is the most commonly fractured long bone! 
• Fractures are at an increased risk of being open due to the minimal amount of subcutaneous tissue between the skin and the bone (though ours was closed). 
• The initial management (of any fracture, really) is analgesia. 
• Lower grade fractures may be appropriately treated by closed reduction, splinting/casting, and outpatient follow up. However, any higher grade fracture, significant mechanism of injury, or injury with significant edema concerning for compartment syndrome will require immediate Orthopedic consultation, admission for compartment checks, and likely expedited operation. 
• Briefly, remember the 6 P’s of compartment syndrome:
• Pain out of proportion to exam
• Paresthesias
• Pallor
• Paralysis
• Poikilothermia (affected limb is cooler)
• Pulselessness (occurs late)
• See former EM Daily Post here to further review the basics of compartment syndrome.
• measure compartment pressure with a manometer
• normal compartment pressures are below 10 mmHg, usually >30 mmHg considered threshold for level at which tissue death may occur
• When in doubt, call orthopedics early! If you’re at a community site without an orthopedic consultant on site and you’re worried about compartment syndrome, you can instead consult the acute surgery team and work with them to form a plan. 

Schatzker Classification of Tibial Fractures:

Outcome: Within two hours of presenting to the ED, our Orthopedic surgery team took the patient directly to the operating room and performed an external fixation and four compartment fasciotomies. Three days later, he was taken back to the OR for fasciotomy irrigation and debridement with primary wound closure of medial and lateral wounds, and five days later he went back to the OR for definitive treatment with open reduction & internal fixation of his tibial plateau fracture.

References:

• Haller, P. Leg Injuries. In: Tintinalli JE, Stapczynski JS, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2016: (Ch) 275. 
• A.M.F. El Kharboutly Multi-detector computed tomography assessment of the tibial plateau fractures. Egypt J Radiol Nucl Med, 46 (3) (2015), pp. 695-699.