Delay in diagnosis of compartment syndrome

by Wayne Wenske, Senior Marketing Strategist

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Presentation

On June 6, a 64-year-old woman was taken by ambulance to the emergency department (ED) of a large hospital after falling down a staircase in her home. The patient reported left leg pain, low back pain, and neck pain. She had a history of coronary artery disease with prior coronary artery bypass graft, hypertension, and hyperlipidemia. Her medications were aspirin 81 mg daily, lisinopril, metoprolol, and rosuvastatin.

Physician action

The patient was evaluated by an emergency medicine physician who ordered multiple x-rays. The films revealed an intra-articular tibial plateau fracture with fragments displaced laterally and a comminuted fracture of the left tibia and fibula.

The on-call orthopedic surgeon, Orthopedic Surgeon A, was consulted by phone at approximately 5:30 p.m. and admitted the patient. At 12:35 a.m., the nurses phoned Orthopedic Surgeon A to notify him that the patient had uncontrolled pain and numbness; he ordered morphine sulfate 2 to 10 mg IV every two hours and ice to the left knee. 

Orthopedic Surgeon A saw the patient the next morning and documented that her left leg was extremely swollen and tender with tight compartments; the left foot was warm with diminished sensation; the dorsalis pedis pulse was not palpable; and there was no active motion of the left ankle or toes due to leg pain. 

His assessment was “left tibial plateau fracture with impending compartment syndrome.” He recommended compartment release with a delayed open reduction and internal fixation (ORIF) surgery. The patient understood the severity of the injury and agreed to surgery. 

Later that day, Orthopedic Surgeon A performed a left leg compartment release. Incisions were made in the medial and lateral left leg. The lateral incision was made through the fascia; the fascia was released proximally and distally, and a deep posterior compartment was also released. A large amount of hematoma was released from the medial incision. Compartments were noted as softer at the end of the procedures. Capillary refill improved but the dorsalis pedis pulse was not palpable. A long leg posterior splint was applied. No complications were noted. 

On June 10, Orthopedic Surgeon A took the patient back to surgery and performed an ORIF of the left tibial plateau and compartment incision closure. 

On June 11, the patient reported pain and inability to feel or move her foot. Her anterior ankle had blistering and there were changes to her skin color. Her leg was tender with moderate swelling; her foot was warm with no sensation and with passive ankle dorsiflexion; her dorsalis pedis pulse was weak; and she had diminished muscle strength. The dressing was noted as clean and dry. Orthopedic Surgeon A ordered continued observation of the foot, immobilization, and discontinuation of ice. 

From June 12 to 13, the ankle swelling and blistering continued. The compartments were soft. The patient was intermittently feverish and could not move or feel her foot. Her foot was described as warm, capillary refill at 2 seconds, normal muscle strength and symmetric reflexes. White blood cell count was 13,900 and hemoglobin 8.4. A chest x-ray showed atelectasis and a small infiltrate. She was given penicillin injections. The patient’s family requested that she be transferred to another hospital.

Orthopedic Surgeon A met with the patient and her family on June 14. He addressed their concerns about the patient’s care. During this visit, the left lateral incision had serosanguineous drainage and discoloration in the mid incision along with early eschar. The foot had large clear blisters. There was slight movement of the ankle, but no toe movement. The compartments were noted as soft. The possibility of an infected hematoma was noted. Incision and drainage (I&D) surgery was scheduled for June 16. 

The patient’s family again expressed concerns about her care. They requested an x-ray of the left foot and a second orthopedic opinion. Orthopedic Surgeon A ordered the x-ray but explained that a second orthopedic opinion would delay the I&D surgery. The patient decided to forgo the second opinion and proceed with the I&D surgery.

On June 16, Orthopedic Surgeon A performed the I&D surgery with a wound vac placement. The patient’s status was noted as “post I&D of the left leg with excision of dead lateral compartment musculature.” The patient was scheduled to return to surgery with Orthopedic Surgeon B for debridement. Orthopedic Surgeon A also requested a second opinion from Orthopedic Surgeon C.

Orthopedic Surgeon C saw the patient on June 17. She documented that the diagnosis and treatment by Orthopedic Surgeon A were appropriate and agreed with his plan for continued I&D surgeries, antibiotics, and possible soft tissue coverage. Additional antibiotics were added to the patient’s medications. The patient’s family was informed of the second opinion and agreed with Orthopedic Surgeon C’s assessment.

On June 18, Orthopedic Surgeon D took the patient to surgery for additional I&D. He found 
necrotic muscle in the lateral and inferior and deep posterior compartments of the left leg. Necrotic muscle was encountered extending down to the ankle and the whole anterior and lateral compartments were necrotic. All muscle was found to be nonviable. By incising the intramuscular septum between the tibia and fibula, the deep posterior compartment was seen to be completely necrotic. 

The medial incision was debrided, and the superficial posterior compartment was the only viable muscle found. The leg was deemed “unreconstructable and unsalvageable.” 

A recommendation for an above the knee (AK) amputation was made to the patient. She agreed to the procedure, and a standard AK amputation was performed. On July 2 the patient was discharged and admitted to a rehabilitation hospital. She was discharged to home on July 6. 

Allegations

A lawsuit was filed against Orthopedic Surgeon A for delay in diagnosis and treatment of compartment syndrome.

Legal implications

Physicians who reviewed this case for the defense were critical of Orthopedic Surgeon A for his delay in recognizing and treating compartment syndrome. One physician noted his concern that Orthopedic Surgeon A performed an ORIF surgery on the patient when she was still displaying signs of vascular compromise. Rather, a vascular surgery consult could have been obtained and the defendant could have performed a minimally invasive repair with an external fixator.

Physician consultants who reviewed the case for the plaintiff were also critical of Orthopedic Surgeon A. One consultant stated that the defendant should have immediately recognized the severity of the fractures and the risk for compartment syndrome. Another plaintiff’s expert asserted that the standard of care required Orthopedic Surgeon A or a vascular surgeon to immediately come to the hospital to examine the patient. 

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Disposition

This case settled on behalf of Orthopedic Surgeon A.

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