In this prospective study, we evaluated the analgesic efficacy of the Hi-PAC block in below-knee surgeries. The high-volume proximal adductor canal (Hi-PAC) block has been described as a procedure-specific and motor-sparing RA technique appropriate for below-knee surgeries. Avoiding RA for fear of presumed masking of symptoms and delaying CS diagnosis may not be a solution instead of choosing an appropriate RA with regular postoperative monitoring for such warning symptoms. Timely diagnosis and treatment of CS require vigilant postoperative monitoring of the warning signs by trained staff. The pain out of proportion to the surgery or injury is a typical symptom of developing CS, which can cause increased analgesic demands postoperatively.

Therefore, patients should not be deprived of their right to remain pain-free in the postoperative period by compromising the analgesia protocol. Also, the presence or absence of RA cannot prevent or promote the development of CS. The analgesia quality makes a big difference when compared with or without RA. Like any other surgery, below-knee surgeries have significant postoperative pain that requires effective postoperative analgesia protocol. Compartment syndrome (CS) has been found frequently in below-knee surgeries, particularly among tibial diaphyseal fractures.

Complications of rhabdomyolysis and severe electrolyte derangements – i.e.The consideration of regional analgesia (RA) in below-knee surgeries is always a controversial topic due to the fear of masking symptoms of developing compartment syndrome in the postoperative period.

Failure to recognize in compartments other than the calf – i.e., thigh.

Vascular service – may perform the fasciotomy at the time of vascular repair if trauma surgery is not immediately available Orthopedic service – any extremity with a fracture or dislocation

ischemic vascular injury associated with shock.

compartment syndrome unequivocally diagnosed on physical exam.

At the conclusion of the case, the primary surgeon will call the trauma faculty if a fasciotomy was not performed prior to leaving the OR. Ultimately, the final decision to perform a fasciotomy is the responsibility of the attending trauma surgeon. The involved faculty should have a brief but focused discussion regarding priorities of care and the need for fasciotomy. Since it is common to underestimate the time from injury to restoration of blood flow, by default, all complicated extremity injuries will receive a complete fasciotomy unless all involved faculty members believe the fasciotomy is unnecessary based on known ischemic time and physiology. Patients are taken to the general trauma or hybrid OR (not HVI) at the discretion of the trauma faculty and orthopedic service with a vascular surgery consult as determined by the trauma attending. The coordination of multiple surgical services (Trauma, Orthopedic, Vascular, and Plastics) to expedite patient care is paramount for optimal outcome and is the responsibility of the Trauma Service. Any patient in the ED with suspected vascular injury and/or compartment syndrome should have prompt consultation with the trauma service prior to definitive imaging or compartment pressure evaluation.

Trauma patients with combined orthopedic and vascular injuries are immediately evaluated by the trauma service. Purpose: To delineate management of peripheral compartment syndrome in multiply injured patients.

Compartments of leg fasciotomy