Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a Foundation Year Doctor working in the Emergency Department. Your next patient is a 26-year-old gentleman (Jordan Ramsey) presenting with leg pain. Please take a history and perform an appropriate examination.
Patient History:
Your name is Jordan Ramsey – a 26-year-old rugby player.
While playing rugby 1-2 hours ago, you tripped and fell over while running at high speed after being tackled. Afterwards, You noticed severe pain in your right lower leg following the accident – rating it 10/10. The pain also tends to radiate and up and down the leg. It is worsened by any movement. Your coach thinks you fractured one of your bones in the leg and therefore called for an ambulance. Since then, you put a tight splint in place to help stabilise a potential fracture and stop it from getting any worse. You were given morphine in the ambulance which helped a bit.
Since the injury, you can feel numbness and tingling sensation over the lower right leg, it is also becoming increasingly pale and swollen. You are unsure if there's any weakness as it is too painful to move your leg. Your calf feels extremely tight.
No fever. No recent infection. No rigors. No involvement in joints.
Ideas, Concerns, Expectations:
You think you have a fracture for sure because of the pain you are having. You are concerned because it is getting worse, and you start to not be able to feel the leg, and it is getting more swollen. You hope to get this fixed as soon as possible in any way and want a stronger pain killer. You cannot bear this anymore!
Past Medical History:
Von Willebrand disease
Drug History:
Nil Adverse reaction to penicillin (sickness)
Family History:
Nil significant
Social History:
You work as a chef in a busy restaurant in town.
You do not smoke or drink.
You live with your partner in a flat currently.
Examination Findings:
Tenderness on palpation on the lower leg (right) with swelling and paleness. Pulses are present at posterior tibialis + dorsalis pedis and popliteal/femoral region. Weakness and limited movement in active/passive movement below the right ankle due to pain and swelling. Increased capillary refill time at right lower leg. Reduced sensation below the right ankle.
Differentials:
Compartment Syndrome secondary to trauma + worsened by splint
Fracture
Other soft tissue injuries
Haematoma
Investigations:
Clinical diagnosis
Urine dip (urine dip/urine myoglobin if rhabdomyolysis/ tissue necrosis is suspected)
Bloods (routine bloods, blood culture if infection suspected, CK + U&Es)
Needle manometry/ slit catheter/infusion techniques (to measure compartment pressure)
XR (rule out fracture as a cause)
US with doppler (exclude thrombus/occlusion)
Consider MRI scan if unsure
Management: